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Percutaneous nephrolithotomy (PCNL) is the gold-standard treatment for large and complex renal stones. Though associated with higher stone-free rates compared to other minimally invasive stone procedures, this comes at the expense of increased morbidity including postoperative pain and discomfort. We describe our enhanced recovery after surgery (ERAS) protocol for PCNL with emphasis on the use of erector spinae plane blocks to improve patient satisfaction and reduce postoperative opioid use and bother.

Introduction & Objective: Surgical complications are difficult to predict, despite existing tools. Frailty phenotype has shown promise estimating postoperative risk among the elderly. We evaluate the use of frailty as a predictive tool on patients undergoing percutaneous renal surgery., Methods: Frailty was prospectively analyzed using the Hopkins Frailty Index, consisting of 5 components yielding an additive score: patients categorized not frail, intermediate, or severely frail. Primary outcomes were complications during admission and 30-day complication rate. Secondary outcomes included overall hospital length of stay (LOS) and discharge location., Results: A total of 100 patients recruited, of whom five excluded as they did not need the procedure. A total of 95 patients analyzed; 69, 10, and 16 patients were not frail, intermediate, and severely frail, respectively. There were no differences in blood loss, number of dilations, presence of a staghorn calculus, laterality, or location of dilation. Severely frail patients were likely to be older and have a higher American Society of Anesthesiologists score and Charlson comorbidity index. Patients of intermediate or severe frailty were more likely to exhibit postoperative fevers, bacteremia, sepsis, and require ICU admissions (P < 0.05). Frail patients had a longer LOS (P < 0.001) and tended to require skilled assistance when discharge (p < 0.0001)., Conclusions: Frailty assessment appears useful stratifying those at risk of extended hospitalization, septic complications, and need for assistance following percutaneous renal surgery. Risks of sepsis, bacteremia, and post-operative hemorrhage may be higher in frail individuals. Preoperative assessment of frailty phenotype may give insight into treatment decisions and represent a modifiable marker allowing future trials exploring the concept of "prehabilitation"., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

LeGrand N. Denslow (1852-1918) was a pioneer of American dermatology and one of its most controversial figures. His professional career revolved around the cities of New York; St. Paul; Minnesota; and London, England. In 1885, he became professor of skin diseases and genitourinary surgery, and secretary of the St. Paul Medical College, thus making him one of the earliest dermatologists to practice in the state of Minnesota. In 1908, Denslow created a sensation in the news media when he announced, in a paper read before the New York Academy of Medicine, that he had cured patients suffering from tabes dorsalis by treating various abnormalities that he had found in their urethras. Although some American physicians hailed Denslow's "cure" as a major advance in the treatment of tabetic patients, other physicians denounced his treatments as being worthless or, at best, providing minimal and transient symptomatic benefits. This contribution presents the highlights of Denslow's personal life and professional career. It also describes his urologic treatment of tabes dorsalis and the controversy that surrounded it., Competing Interests: Declaration of competing interest No conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To assess for usefulness and validity evidence for incorporating the C-Arm Trainer (CAT) simulator into the annual AUA hands on course for training percutaneous nephrolithotomy (PCNL)., Materials and Methods: The course started with a didactic session followed by four stations for training the "bull's eye" technique using the CAT simulator. Each station included a pre-test, 30-min practice on the simulator, and post-test. All participants were assessed using a 4-item checklist. All participants were asked to fill in a qualitative self-assessment questionnaire after the pre- and the post-test, and respond to a course evaluation questionnaire and post-course survey., Results: A total of 38 physicians, who attended the hands on course, voluntarily participated in the study. Only 21.1% had previous practice on PCNL simulators. Compared with the results of the checklist total score and the qualitative self-assessment questionnaire scores after the pre-test, there was significant improvement in the checklist total score (p < 0.001), temporal demands (p = 0.003), situational stress (p = 0.003, and performance (0.003) after the post-test. A total of 14 (36%) participants responded to the course evaluation questionnaire, 50% evaluated the course as excellent, 28.6% as very good, and 21.4% as good. Unfortunately, only five (13%) participants responded to the post-course survey, 4/5 implemented the new competencies and knowledge into their practice, and 3/5 have attempted to obtain fluoroscopic guided PCA without assistance., Conclusion: The CAT simulator was considered useful for training the percutaneous renal access procedure. There was significant improvement in the qualitative and quantitative assessment parameters after the post-test compared with the pre-test.

Objective: To expand the diagnostic armamentarium for medullary sponge kidney (MSK), we evaluate the use of high-resolution multidetector computed tomography (MDCT) for MSK diagnosis and compare to the standard intravenous urography (IVU). Despite a significant prevalence amongst stone formers, diagnosis of this well described condition has declined. IVU, the gold standard in MSK diagnosis, has largely been replaced by CT, which has previously been shown unable to demonstrate signs of MSK., Methods and Materials: Patients with known history of MSK based on IVU underwent limited MDCT urogram. Control group patients, without MSK, also had MDCT urograms performed for other clinically indicated conditions. Studies were scored by board-certified radiologists on a 0-2 scale based on the likelihood of MSK. IVU studies, when available, were similarly graded., Results: MDCT was diagnostic of MSK in 9 out of the 10 patients with known history of MSK. No false positives were present in our series. The one case of MSK not detected on MDCT was graded as a "1" on its respective IVU. Sensitivity and specificity were 90 and 100%, respectively, when compared with IVU., Conclusion: Concordance with IVU findings, despite a small reduction in sensitivity, indicates MDCT to be a suitable, and more readily available replacement for IVU in the diagnosis of MSK.

As the number of Americans aged 65 years and older continues to rise, there is projected to be a corresponding increase in demand for major surgeries within this population. Consequently, it is important to utilize accurate preoperative risk stratification techniques that are applicable to elderly individuals. Currently, commonly used preoperative risk assessments are subjective and often do not account for elderly-specific syndromes that may pose a hazard for geriatric patients if not addressed. Failure to accurately risk-stratify these patients may increase the risk of postoperative complications, morbidity, and mortality. Therefore, we aimed to identify and discuss the more objective and better-validated measurements indicative of poor surgical outcomes in the elderly with special focus on frailty, patient optimization, functional status, and cognitive ability.

Objective: We compared postoperative outcomes and quality of life (QoL) between patients who received a nephrostomy tube vs a ureteral stent following percutaneous nephrolithotomy (PCNL) in a prospective, double-blind, randomized manner., Materials and Methods: Between September 2015 and March 2016, we randomized 30 patients undergoing PCNL to receive nephrostomy drainage (Group 1: 8F or 10F) or Double-J ureteral stent (Group 2) at conclusion of surgery. Nephrostomy tubes were removed within 48 hours (before discharge) and ureteral stents were removed at least 2 weeks after surgery. Patients' QoL was assessed with the Wisconsin StoneQOL questionnaire preoperatively and then 7 to 10 days and 30 days following surgery. Inclusion criteria included an uncomplicated procedure, normal preoperative renal function, and clinically insignificant residual stone fragments on postoperative imaging. We calculated the preoperative and postoperative QoL score difference between the two groups. We also evaluated perioperative characteristics, inpatient analgesic requirements, length of stay (LOS), and postsurgical complications., Outcome: Patient characteristics between Groups 1 and 2 were comparable with similar age (58.3 vs 54.7, p = 0.534), gender ratio, and stone burden (276.6 mm 2 vs 259 mm 2 , p = 0.84) and composition. There was no significant difference between perioperative outcomes, including stone-free rate (93.3% vs 86.7%), operative times (125.7 minutes vs 115 minutes, p = 0.29), estimated blood loss (103.3 mL vs 100.7 mL, p = 0.9), LOS (3.2 days vs 1.9 days, p = 0.1), and complications (2 in each group). Inpatient analgesic requirements were also the same (both 21.1 mg, p = 1.0). Assessment of QoL using the Wisconsin StoneQOL questionnaire showed significant differences between preoperative and postoperative health-related QoL in 18 of the 28-question instrument at 7 to 10 days. Patients in Group 2 had significantly worse QoL change and a multitude of negative responses on the StoneQOL assessment, not only those commonly associated with stent irritation. Eighty percent of participants in Group 2 also attributed their complaints to having a stent placed. Both groups had similar QoL status at 30 days after surgery., Conclusion: Despite the literature advocating "tubeless" PCNL with ureteral stent placement at conclusion of surgery, our randomized prospective study shows that QoL is significantly worse with stent placement than with temporary nephrostomy drainage in the immediate aftermath following PCNL, using a validated QoL assessment instrument specific for nephrolithiasis.

Extrinsic malignant compression of the ureter is not uncommon, often refractory to decompression with conventional polymeric ureteral stents, and frequently associated with limited survival. Alternative options for decompression include tandem ureteral stents, metallic stents and metal-mesh stents, though the preferred method remains controversial. We reviewed and updated our outcomes with tandem ureteral stents for malignant ureteral obstruction, and carried out a PubMed search using the terms "malignant ureteral obstruction," "tandem ureteral stents," "ipsilateral ureteral stents," "metal ureteral stent," "resonance stent," "silhouette stent" and "metal mesh stent." A comprehensive review of the literature and summary of outcomes is provided. The majority of studies encountered were retrospective with small sample sizes. The evidence is most robust for metal stents, whereas only limited data exists for tandem or metal-mesh stents. Metal and metal-mesh stents are considerably more expensive than tandem stenting, but the potential for less frequent stent exchanges makes them possibly cost-effective over time. Urinary tract infections have been associated with all stent types. A wide range of failure rates has been published for all types of stents, limiting direct comparison. Metal and metal-mesh stents show a high incidence of stent colic, migration and encrustation, whereas tandem stents appear to produce symptoms equivalent to single stents. Comparison is difficult given the limited evidence and heterogeneity of patients with malignant ureteral obstruction. It is clear that prospective, randomized studies are necessary to effectively scrutinize conventional, tandem, metallic ureteral and metal-mesh stents for their use in malignant ureteral obstruction., (© 2015 The Japanese Urological Association.)

The objective of this study was to identify the independent effect of visceral fat on urine constituent excretion in a stone forming population. Using a database of 382 kidney stone patients with available visceral fat quantification, we created multiple linear regression models predicting changes in urinary solutes based on visceral fat area and body mass-index, divided by gender. Chi-square tests were used to compare stone composition by body mass-index and visceral fat area. Visceral fat predicts increases in urinary creatinine, sodium, and volume in men, but only urinary phosphate in women. In women, total body mass-index does not appear to modify this effect, but in men it is more pronounced in overweight patients for creatinine and volume only. Elevated visceral fat is associated with increased probability of uric acid stone composition. Different fat compartments likely effect urine composition in different ways. This effect appears to be different in men and women. Understanding and quantifying the effects of different fat compartments is probably important to understanding the metabolism of urolithiasis.

Objective: To examine the differences in 24-hour urine parameters and stone composition between patients with and without systemic hypertension (HTN) in a large cohort of stone formers., Materials and Methods: We performed a retrospective review over a 10-year period of patients with stone, who had completed a 24-hour urinalysis (Litholink) and for whom demographic information was available, including the presence of HTN. Univariate and multivariate analyses were performed, comparing the 24-hour urinalysis profiles of patients with HTN with that of normotensive patients., Results: Of the 1115 patients eligible for inclusion, 442 patients (40%) had HTN and 673 (60%) did not. Patients with HTN were significantly older, had a higher body mass index, and had a greater number of comorbid conditions than normotensive patients. Univariate analysis revealed significantly lower urine pH, calcium, supersaturation (SS) of calcium oxalate (CaOx) and SS calcium phosphate (all P <.05) in patients with HTN. Multivariate analysis showed significantly lower calcium, citrate, and SS CaOx in patients with HTN (all P <.05)., Conclusion: Our results demonstrate lower levels of calcium and SS CaOx on univariate and multivariate analysis, as well as lower levels of citrate on multivariate analysis in patients with HTN. These results suggest that lower levels of citrate may contribute to stone formation to a greater degree in patients with HTN than abnormalities in calcium metabolism., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Aspirin, as an inhibitor of platelets, is traditionally discontinued prior to percutaneous nephrolithotomy (PCNL) given the concern for increased surgical hemorrhage. However, this practice is based on expert opinion only, and mounting evidence suggests holding aspirin perioperatively can be more harmful than once thought. We sought to compared PCNL outcomes and complications in patients continuing aspirin to those stopping aspirin perioperatively., Methods: A retrospective review was performed of 321 consecutive PCNLs done between July 2012 and March 2014. Patients were separated into two groups. The on-aspirin group consisted of patients continuing aspirin throughout the perioperative period. The off-aspirin group had aspirin held temporarily pre- and postoperatively. Surgical outcomes and complications were compared between groups., Results: Of the 321 PCNLs, 60 (18.7%) occurred in patients chronically taking aspirin. The on-aspirin group included 17 PCNLs (5.2%), while the off-aspirin group included 43 PCNLs (13.4%). There were no differences between groups in terms of operative time (77 minutes vs 74 minutes, p=0.212), hemoglobin change (p=0.522), stone size (21 mm vs 22 mm, p=1.0), stone-free rate (p=0.314), median length of hospitalization (p=0.642), transfusion rate (p=0.703), or total complications (p=1.0). No patient experienced a thromboembolic event., Conclusions: PCNL is safe in patients continuing aspirin perioperatively and does not result in more blood transfusions, angioembolization procedures, or complications. Patients with large stone burdens who are at high risk for thromboembolic events appear to be able to safely undergo PCNL without discontinuing aspirin.

Objective: To determine the feasibility and safety of performing percutaneous nephrolithotomy (PCNL) in high-cardiovascular risk patients remaining on aspirin therapy., Methods: We retrospectively reviewed all PCNLs performed by 3 fellowship-trained endourologists at a single institution between July 2012 and January 2014. All patients remaining on aspirin for imperative indications through the day of surgery were evaluated for surgical outcomes and thromboembolic events., Results: Of 281 PCNL procedures performed during the study period, 16 (5.7%) were performed in 14 patients taking aspirin, uninterrupted, through surgery. Mean surgery time was 66 minutes, mean estimated blood loss was 161 mL, and mean length of hospital stay was 2.8 days. All patients were stone free. There were no intraoperative complications. A total of 5 patients experienced a postoperative complication (n = 4, Clavien grade II; n = 1, Clavien grade IIIa). No patient experienced a perioperative thromboembolic or cardiac event. Three patients required a blood transfusion postoperatively, and none experienced delayed renal bleeding., Conclusion: PCNL can be performed safely and effectively in high-cardiovascular risk patients continuing aspirin perioperatively. Compared with the potential sequelae of a thromboembolic or cardiac event, PCNL is associated with an acceptably low transfusion rate, and should be considered a viable treatment option for large renal stones in this population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Obesity is a risk factor for metabolic syndrome and urolithiasis, particularly uric acid stones. As estimated by visceral fat area, visceral obesity is a more specific measure of the risk of metabolic syndrome than body mass index. We investigated the effects of visceral fat area and other metabolic factors on uric acid stone formation in patients treated with percutaneous nephrolithotomy., Materials and Methods: We retrospectively reviewed the records of 269 patients who underwent percutaneous nephrolithotomy. Visceral fat area was measured in each patient on a CT axial slice at the umbilical level using the Aquarius iNtuition fat analysis tool. Analysis was performed to determine the effect of visceral fat area and other comorbidities on uric acid stone formation., Results: Of the 269 patients analyzed there was no difference in baseline comorbidities between uric acid and nonuric acid stone formers. Patients with uric acid stones had a significantly higher mean visceral fat area (209.3 vs 161.9 cm², p = 0.001), and rates of hypertension (67.4% vs 47.3%) and coronary artery disease (14.3% vs 4.6%, each p = 0.011). On logistic regression analysis hypertension (OR 2.16, 95% CI 1.05-4.45, p = 0.04) and a high visceral fat area (OR 3.64, 95% CI 1.22-10.85, p = 0.02) were independent risk factors for uric acid stones., Conclusions: As a marker of visceral obesity, visceral fat area contributes to the risk of metabolic syndrome and urolithiasis. Uric acid stone formers showed a significantly higher hypertension rate and mean visceral fat area, which were independent risk factors for uric acid urolithiasis. Evaluating these characteristics in stone formers may facilitate a tailored metabolic assessment and treatment plan., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Renal preservation in selected patients with upper-tract urothelial cancer (UTUC) has been well described, offering an alternative to radical nephroureterectomy. We present our experiences in performing percutaneous treatments after neoadjuvant chemotherapy in one such patient with a large, complex, high-grade UTUC in a solitary kidney., Case Report: A 55-year-old woman with a solitary kidney presented with a 5.2 cm enhancing mass with calcifications involving the left renal pelvis and lower pole. Cystoscopy and retrograde pyelography demonstrated normal bladder mucosa. Ureteroscopy revealed a large, papillary tumor occupying the renal pelvis. Ureteroscopic treatment was deemed impossible because of the lesion's volume. We proceeded with percutaneous resection after downsizing the tumor after a course of neoadjuvant chemotherapy. Using a 25F resectoscope via a percutaneous tract, resection was performed to fully excise the tumor, and the patient received two postoperative chemotherapy courses. A recurrence developed within an isolated calix 8 months postoperatively, which was also managed percutaneously., Conclusion: A multimodal approach in a highly motivated patient could represent a reasonable strategy for patients in whom such a therapy is desired.

Importance of the Field: Although transurethral resection of bladder tumor (TURBT) is effective therapy, up to 45% of patients will have a recurrence within 1 year after TURBT alone. Further, there is a 3 - 15% risk of tumor progression to muscle invasive and/or metastatic cancer. Depending on patient and tumor characteristics, a number of patients may benefit from some form of intravesical therapy. Adjuvant therapy is effective in avoiding post-TURBT implantation of tumor cells, eradicating residual disease, preventing tumor recurrence, and to delay or reduce tumor progression through direct cytoablation or immunostimulation., Areas Covered in This Review: The role of risk assessment in the management of nonmuscle invasive bladder cancer (NMIBC) and the indications for the use of intravesical agents are discussed. Findings from major randomized clinical trials on BCG, interferon and various chemotherapeutic agents are summarized; key aspects of drug pharmacology, drug efficacy, side effects, and toxicity are also covered., What the Reader Will Gain: The reader will gain a basic understanding of the role of risk assessment in determining the need for intravesical therapy, as well as an overview of the different types of agents in use in the United States today., Take Home Message: The type of intravesical therapy used is based on the risk groups as noted in the European prognostic tables. Bacillus Calmette-Guerin (BCG) is the most commonly used first-line agent immunotherapeutic agent for prophylaxis and treatment of carcinoma in situ and high-grade bladder cancer. Other immunotherapeutic options include the interferons, interleukins 2 and 12, and tumor necrosis factor, all of which have activity in BCG refractory patients, although with low durable remission rates. Studies have shown that chemotherapy prevents recurrence but not progression. The available data on intravesical chemotherapy do not indicate that any single agent currently in use is clearly better than any other. Therefore, the selection of a chemotherapeutic agent is usually based on cost, toxicity, and availability as well as on physician preference and experience.

Shock wave lithotripsy (SWL) has been a major tool in the treatment of urinary stones for nearly three decades. In recent years, SWL technology has been less effective at fragmenting stones than earlier devices; thus, adjunctive maneuvers to improve stone-free rates after SWL have been required. This article summarizes several of these adjuncts, such as slower shock wave rate, the use of percussion therapy to clear fragments, medications to hasten expulsion of fragments, and appropriate selection and positioning of patients for SWL.

Various options are available for the treatment of patients with large, bilateral renal stones, including a staged percutaneous nephrostolithotomy (PCNL), synchronous PCNL with contralateral ureterorenoscopy, and synchronous bilateral PCNL. For patients with large bilateral renal stones, a synchronous bilateral PCNL may be offered if particular criteria are met. Overall outcomes reported for synchronous bilateral PCNL include high stone-free rates (95%-97%), low complication rates (9%-12%), short length of hospital stay (4-6 days), and low blood transfusion rates. Detailed cost analysis has revealed a significant cost advantage for synchronous vs staged bilateral PCNL; however, reimbursement practices reveal a significant financial disincentive for the surgeon to perform simultaneous bilateral PCNL. Here, we review the experience and current recommendations with synchronous bilateral PCNL for the treatment of patients with large, bilateral renal calculi.

Purpose: We evaluated any correlation between measured renal parenchymal area on computerized tomography and differential function on (99m)technetium-mercaptoacetyltriglycine renal scan to ascertain whether computerized tomography measurements could predict differential renal function., Materials and Methods: Between 2005 and 2007 we identified 111 patients who underwent computerized tomography and renal scan. Average renal parenchymal thickness was calculated by measurements made at the upper and lower poles of each kidney. The product of average renal parenchymal thickness and renal length was calculated bilaterally and the ratio of parenchymal area was compared to the differential shown on renal scan., Results: The average difference between predicted and observed renal function was 4.73% (Pearson's correlation coefficient 0.959). Patients with positive urine cultures at renal scan were compared to the other 89. The average functional difference was 6.54% vs 4.28% (Pearson's correlation 0.955 vs 0.965, p = 0.0045). The 89 uninfected patients were then compared based on contrast vs noncontrast computerized tomography and obstructed vs unobstructed renal units. No statistical difference was found with contrast administration. When compared based on evidence of obstruction, unobstructed kidneys resulted in a lower Pearson correlation (0.743 vs 0.975) but they had a statistically significant average functional difference in favor of unobstructed units (3.28% vs 5.10%, p = 0.0036). No difference was found in the obstructed group with prior drain placement., Conclusions: Differential renal parenchymal area measured by computerized tomography strongly correlates with differential function on renal scintigraphy and it may obviate the need for nuclear renal scan in some circumstances.

Purpose: Laparoscopic radical nephrectomy has been accepted as the preferred management for low stage renal masses not amenable to partial nephrectomy. Early in the mid 1990s several studies suggested that obesity should be a relative contraindication to laparoscopy. We present our surgical outcomes and complications in patients undergoing open and laparoscopic nephrectomy, stratified by body mass index., Materials and Methods: We retrospectively identified 88 patients, of whom 43 underwent open nephrectomy and 45 were treated laparoscopically. All patients were stratified by body mass index to compare multiple perioperative end points and pathological outcomes of laparoscopy., Results: Overall our data showed that compared to open nephrectomy laparoscopic nephrectomy resulted in statistically significant lower estimated blood loss (147.95 vs 640.48 cc, p <0.0002), operative time (156.11 vs 198.95 minutes, p <0.003) and hospital stay (3.7 vs 5.9 days, p <0.004). When stratified by body mass index less than 25, 25 to 29.9 and 30 kg/m(2) or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was in favor of the laparoscopic approach in each body mass index category. Operative time did not show a statistical difference in the subgroups but all laparoscopic procedure times were shorter than open procedure times in each body mass index category. When patients with a body mass index of greater than 30 kg/m(2) were further subgrouped into 35 kg/m(2) or greater and 40 kg/m(2) or greater, there was a statistically significant difference in estimated blood loss and hospital stay that was again in favor of the laparoscopic method., Conclusions: Laparoscopic radical nephrectomy is technically more challenging as body mass index increases due to many factors but our data show that it is feasible and safe in experienced hands. Laparoscopy appears to result in perioperative outcomes that are superior to those of open nephrectomy in this high risk population with a complication profile that is equivalent to that of the open method for each stratified body mass index category.

Herein we describe the technique and review the medical records of 26 patients who underwent percutaneous nephrostolithotomy (PCNL) and simultaneous contralateral retrograde ureterorenoscopy (URS) for bilateral urolithiasis of discordant sizes at our institution. Preoperative factors, operative time, change in hemoglobin, change in serum creatinine, stone free, and efficacy rates after a single procedure were analyzed retrospectively. The total efficacy rate--defined as residual calculus of 4 mm or less--was 92.3%. A second look PCNL or URS was used to target any residual calculi; 5 of the 26 (19%) patients required further therapy following the initial intervention. All cases that required a second look were ultimately rendered stone-free. No preoperative factor was statistically significant with respect to treatment failures. In terms of complications, temporary, acute renal insufficiency occurred in 2 patients, (7.7%) and the duration was transient. Performing synchronous PCNL and contralateral retrograde URS is efficient, safe, and not more dramatically lengthy in terms of operative time or morbid in terms of complications when compared to a traditional unilateral percutaneous procedure. In this approach, management of bilateral urolithiasis in one operative procedure is practical and efficacious. The approach allows patients to return to normal activity within the same time period as those having a unilateral approach and to be free of stone without a need for a second, staged procedure.

Image-guided percutaneous renal access for placement of an access sheath for percutaneous nephrolithotomy can be a challenging procedure, especially in patients with nondilated collecting systems, obstructed infundibula (stones or stricture), or extreme body habitus. We describe our experience using ureteroscopy along with a zero-tip stone basket to facilitate a through-and-through (percutaneous-urethra) access to the collecting system.

A 79-year-old woman presented with gross hematuria 10 days after flexible ureteroscopic stone extraction with holmium laser lithotripsy. Work-up revealed a bleeding intrarenal arteriovenous fistula that was embolized. To our knowledge, this is the first report of this complication causing delayed hematuria after ureterorenoscopy.

Pelvic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Although minimally invasive approaches have been described for the management of benign conditions, only a handful of reports have described the use of laparoscopy for removal of ectopic or fused kidneys. We describe the laparoscopic removal of a symptomatic pelvic kidney in a patient before renal transplantation.

Objectives: In the instance of extrinsic ureteral obstruction, indwelling ureteral stents have a high failure rate. Although technically challenging, simultaneous insertion of two ipsilateral stents can achieve better flow rates with time. A novel dual-lumen stent, composed of two adhered ureteral stents, offers the additional benefit of easier placement than a single guidewire. Using a novel ex vivo porcine model, the flow rates within an extrinsically obstructed renal unit were evaluated using two internal ipsilateral stents and two prototype double-lumen stents., Methods: Sixteen renal units were harvested from eight adult Yorkshire female pigs. To quantify flow, the kidneys were infused at a constant pressure, and the corresponding ureteral drainage was measured for a defined interval. The flow was measured with a standard 7F double-pigtail stent, two ipsilateral 7F double-pigtail stents, a 7F novel double-lumen stent designed with both distal lumens open, and a 7F novel double-lumen stent with one distal lumen closed. The intraluminal and extraluminal flow in obstructed and nonobstructed systems was measured., Results: The two ipsilateral standard stents or prototype double stents achieved better flow down the ureter than did one standard stent (P <0.05). The intraluminal and extraluminal flow in the novel stents was statistically greater than the corresponding flow in the standard double-pigtail stent (P <0.01). The extraluminal and obstructed flow was lowest for the standard double-pigtail stent., Conclusions: Novel dual-lumen prototype ureteral stents provided better flow than a single stent in extrinsically obstructed ureters with the proposed added benefit of easier retrograde insertion compared with a single guidewire.

Objectives: To review our experience with minimal fat angiomyolipomas (AMLs) and correlate the confirmed pathologic diagnosis with preoperative radiologic features to evaluate the feasibility of an accurate diagnosis preoperatively. On rare occasions, renal AMLs contain minimal amounts of fat that are not identified on cross-sectional imaging., Methods: From November 1998 to August 2003, 6 patients (seven lesions) underwent renal surgery with the preoperative diagnosis of renal cell carcinoma as determined by preoperative imaging studies, and the finding of AML was unexpected. A single pathologist and radiologist reviewed all pathologic specimens and radiologic examinations. The characteristic findings were recorded and compared with those in published reports., Results: Pathologic review of the specimens demonstrated microscopic amounts of mature adipocytes, abnormally thickened blood vessels, and smooth muscle cells in all seven lesions. The mean estimated fat content was 4.1% (range 3% to 10%). Hounsfield unit measurement of the lesions on unenhanced computed tomography images revealed all lesions to be hyperdense relative to the normal kidney parenchyma and enhanced by at least 90 Hounsfield units or more with the administration of intravenous contrast. Enhancement was homogenous throughout each of the seven masses., Conclusions: Minimal fat renal AML tumors are typically hyperdense relative to the normal kidney parenchyma and demonstrate homogenous enhancement with the administration of intravenous contrast on computed tomography. These results may have important implications when planning partial versus radical nephrectomy by open or minimally invasive techniques.

Splenic laceration is a recognized complication of both open and laparoscopic renal surgery. Laparoscopic renal surgery continues to become the new standard of care, and this potentially problematic complication may be encountered during mobilization to gain access to the retroperitoneum. We present 2 cases of splenic injury managed with BioGlue, a new surgical adhesive, during one hand-assisted and one pure laparoscopic nephrectomy. Application of the BioGlue adhesive resulted in satisfactory hemostasis for both injuries without the need for further intervention. These preliminary observations suggest that BioGlue may be a useful addition to the urologic armamentarium to achieve hemostasis in laparoscopic surgery.

Purpose: To investigate the feasibility and initial outcomes of a combination of ureterorenoscopy (URS) using holmium laser lithotripsy and extracorporeal shockwave lithotripsy (SWL) in a single outpatient session for the treatment of large renal stone burdens in patients refusing or unsuitable for percutaneous nephrolithotomy (PCNL)., Patients and Methods: Fourteen patients with a mean age of 52.7 years (range 34-81 years) having a mean stone burden of 847 mm2 (range 58 mm2-1850 mm2) were treated with combined URS laser lithotripsy and SWL as an alternative to PCNL. The SWL (mean 2800 shockwaves) was performed using the Storz Modulith SL-X, and flexible URS with holmium laser lithotripsy was performed either during or following SWL., Results: Ninety-three percent of the patients (13/14) were treated successfully on an outpatient basis. Two patients were rendered stone free after the initial procedure alone (14%). Overall, including secondary outpatient treatment with a second session of URS alone (N = 7) URS and SWL (N = 1), SWL (N = 1), or oral alkalinization therapy (N = 1), the stone-free rate was 76.9% (10/13). One patient was excluded secondary to death from unrelated causes after the initial procedure, and the success rate (residual fragments <4 mm) was 84.6% (11/13). The two treatment failures included one patient who required a third URS procedure and one patient who developed urosepsis necessitating nephrostomy-tube placement who underwent subsequent PCNL., Conclusions: In comparison with traditional approaches using PCNL and second-look nephroscopy, single-session combined URS and SWL with a second outpatient procedure may offer equivalent results with decreased morbidity in carefully selected patients.

Objectives: Nephron-sparing surgery has emerged as the treatment of choice for the incidentally detected small renal mass, especially those less than 4 cm in size. We describe our technique and experience with the laparoscopic excision of these lesions., Methods: Between June 2001 and October 2003, 20 patients underwent nephron-sparing surgery at our institution. Twenty-one laparoscopic partial nephrectomy procedures were performed. All tumors were detected incidentally by cross-sectional imaging. All patients had a solid renal mass or a complex cystic renal mass of Bosniak category III or greater. All solid tumors were exophytic and less than 4cm in diameter. Both transperitoneal and retroperitoneal approaches were used. Hemostasis was achieved without hilar control in 20 of the 21 cases., Results: Twenty renal units were approached transperitoneally, and 1 retroperitoneally. Mean tumor size was 2.6 cm (range, 1.2 to 4). Mean estimated blood loss was 211 mL (range, 50 to 500), and mean operative time was 165 minutes. Pathology revealed renal cell carcinoma in 14 (70%). No intraoperative complications occurred. Two patients required blood transfusions postoperatively., Conclusion: Carefully selected patients with small, exophytic renal masses can safely undergo laparoscopic excision. When achievable, this procedure can be a more logical alternative to ablative techniques for the minimally invasive management of such lesions.

Purpose: To evaluate the influence of intensive laparoscopic skills training and self-critical video review on the learning curve for laparoscopic radical prostatectomy (LRP)., Patients and Methods: The initial 40 patients who underwent a transperitoneal LRP (groups 1-4) and the subsequent 20 who underwent LRP by the extraperitoneal approach (group 5) were studied. Eight weeks prior to initiating the LRP program, intensive laparoscopic skills training at a minimally invasive surgery center was undertaken for an average of 4 hours per week. This self-training was continued for 12 weeks into the program, with self-critical review of videotapes of each procedure. The groups were compared with respect to total operative time (ORT), anastomosis time, and blood loss., Results: There were significant differences in the ORT and anastomosis times between each of the first two groups and the last two groups (P <0.001). The learning curve for ORT was overcome after approximately 35 cases, as there were no significant differences in ORT between group 3 and the subsequent groups. The anastomosis took longer to master, as significant time decreases were observed up to group 4, after which, the mean reached a plateau (group 4 v 5 P = NS). The differences in blood loss were not significant. Overall, there were 7 intraoperative (12.7%) and 8 postoperative (14.5%) complications., Conclusions: The use of similar facilities and training tools can help overcome the steep learning curve of LRP. Longer follow-up is needed to assess these means of attaining better functional results after LRP.

Background and Purpose: In the evaluation and treatment of patients with urethral strictures, assessment of the stricture is of paramount importance. To date, urologists have relied on retrograde or antegrade urethrography or both to define stricture length and associated characteristics. Antegrade urethrography typically requires suprapubic access to the bladder, adding to the morbidity of stricture treatment. Herein, we describe the feasibility of using a new method for diagnosing, staging, and managing urethral stricture disease., Patients and Methods: Twenty-four men with urethral strictures underwent urethroscopy with a 7.5F, 26-cm "pediatric" flexible cystoscope to stage and manage their disease. Comparison of urethroscopy with retrograde urethrography was made with respect to characterizing the stricture., Results: In all cases, the urethral strictures could be navigated with the 7.5F cystoscope. Documentation of the stricture length and the density of scar tissue and identification and characterization of additional pathology (urethral calculi proximal to the stricture in two patients) were possible in all cases, including four patients with recurrent stricture after complex urethroplasty., Conclusion: The 7.5F, 26-cm pediatric flexible cystoscope represents a useful tool in the diagnosis and management of urethral stricture disease. Further studies will be necessary to determine the cost-effectiveness, patient morbidity, and ability to tailor therapy appropriately in comparison with standard retrograde urethrography or voiding cystourethrography.

Nephron-sparing surgical techniques represent an attractive treatment approach for small renal lesions that are limited only by potential operative morbidity. This study tests the hypothesis that an alternative strategy of in situ cryoablation of these lesions may further reduce the incidence of complications with similar efficacy. Beginning August 1996,17 patients were enrolled in an institutional review board-approved protocol for open renal cryoablation for lesions smaller than 4 cm in diameter. The median age was 62 years (range, 35-75 years). The median preoperative lesion size was 2.0 cm (range, 1.1-4.2 cm) determined with either computed tomography or magnetic resonance imaging. A double freeze-thaw technique to -180 degrees C was used under direct intraoperative ultrasound monitoring. The median length of follow-up was 30 months (range, 10-60 months), with 8 patients followed up for more than 20 months. The procedure was accomplished in 3 hours (range, 2.25-4.25 hours) through a 5-cm to 7-cm subcostal incision. The median blood loss was 100 mL, and the median hospital stay was 2 days (range, 2-8 days). The median intraoperative lesion was 2.4 cm, which was not statistically different from preoperative measurements. Postoperative serum creatinine levels were unchanged except for a transient increase from 5.5 mg/dL to 7.0 mg/dL in one patient. Follow-up magnetic resonance imaging scans have demonstrated infarction and a reduction of lesion size in 15 of 16 cases. The size of one patient's mass was unchanged after 3 months. Renal cryoablation via an open approach is associated with few complications and represents a viable alternative to extirpative surgical techniques. The open exposure provides an accurate assessment of the renal unit with definitive ultrasound visualization.

Purpose: We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi., Materials and Methods: A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group., Results: The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed., Conclusions: Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Objectives: To evaluate the safety and efficacy of open renal cryoablation of small solid renal masses, since the delivery of freezing temperatures has been shown to effectively ablate solid neoplasms of the liver, uterus, and prostate., Methods: A total of 29 patients were treated with open renal cryoablation since December 1996 and followed up to evaluate the treatment safety and initial radiographic response., Results: The median preoperative lesion size was 2.2 cm, with 22 solid renal masses and 7 complex renal lesions. Five serious adverse events occurred in 5 patients, with only one event directly related to the procedure. One patient experienced a biopsy-proven local recurrence, and 91.3% of patients (median follow-up 16 months) demonstrated a complete radiographic response with only a residual scar or small, nonenhancing cyst., Conclusions: Open renal cryoablation appears to be a safe technique for the in situ destruction of solid or complex renal masses. However, inadequate freezing of renal cell carcinoma may result in local disease persistence. The expected slow growth rate of small renal cancers necessitates prolonged radiologic follow-up. Continued clinical research is required before renal cryoablation can be considered an acceptable curative treatment for renal cancer.

Although there has long been debate about the existence of nephroptosis, contemporary radiologic and biochemical studies confirm its existence. Both percutaneous and laparoscopic operations are available for fixing the kidney, with high early success rates. Objective documentation of the diagnosis is mandatory. Further studies with validated quality-of-life and pain questionnaires are needed to determine the long-term success of nephropexy.

The use of laparoscopy for ureteral surgery, currently in its relative infancy, is critically reviewed here as an alternative to traditional open and endoscopic methods. The technical aspects of laparoscopic ureteral surgery, clinical and experimental experience to date, and recent advances in anastomotic and substitutive technology are discussed., (Copyright 2000 by W.B. Saunders Company)

Background and Purpose: Stent morbidity appears to be secondary to lower urinary tract irritation. In an effort to decrease stent morbidity, a "one size fits all" Tail stent (Microvasive [Boston Scientific] Natick, MA) was developed with a 7F proximal pigtail and 7F shaft which tapers to a lumenless straight 3F tail., Patients and Methods: We randomized 60 patients in a single-blind fashion to a 7F tail stent or 7F double-pigtail Percuflex stent. Patients were evaluated at the time of stent removal and 2 weeks later with a standardized questionnaire assessing: irritative lower tract symptoms individually and on a total scale of 0 (no symptoms) to 30 (worst symptoms), obstructive lower tract symptoms (on a total scale of 0-20), and upper tract irritative symptoms (on a total scale of 0-10)., Results: Patient age, weight, and height were similar in the two groups. Complications, including fever, urinary tract infections, emergency room visits, and the need for antispasmodics and pain medication, also demonstrated no significant difference. At the time of stent removal, patients who received a tail stent had significantly less urinary frequency and a statistically significant (21%) decrease in overall irritative voiding symptoms (12.2 v 15.4; p = 0.048). Two weeks after stent removal, the total irritative voiding symptoms was markedly decreased in both groups (7.1 in the Tail v 5.3 in the double-pigtail group; p = 0.15). Obstructive bladder and flank symptoms were not significantly different in the two stent groups, either at the time of stent removal or at 2 weeks after removal., Conclusion: In this randomized, single-blind study, the 7F Tail stent produced significantly less irritative symptoms than did the standard 7F double-pigtail stent. Obstructive symptoms tended to be less with the new stent, while flank symptoms were similar.

Purpose: We evaluate our experience with endopyelotomy for ureteropelvic junction obstruction by stratifying the results of an antegrade versus a retrograde approach for primary, secondary, calculi related, high insertion and impaired renal function related obstruction, individually., Materials and Methods: We retrospectively reviewed results of 149 nonrandomized patients treated for ureteropelvic junction obstruction, of whom 83 underwent antegrade percutaneous endopyelotomy using a right angle Greenwald electrode and 66 underwent retrograde endopyelotomy using a cutting balloon device. Subjective results were based on an analog pain scale, objective results on renal scan, excretory urography or Whitaker test and cost-effectiveness analysis on total treatment cost., Results: In both primary and secondary ureteropelvic junction obstruction, retrograde endopyelotomy was related to a significantly shorter operating room time and hospital stay (p < 0.05). When treating noncalculous primary ureteropelvic junction obstruction (92 patients) there was a better objective, albeit not statistically significant, success rate with antegrade endopyelotomy (89 versus 71%) but retrograde endopyelotomy was 20% more cost-effective. When treating secondary ureteropelvic junction obstruction (37 patients) there was a better objective, albeit not statistically significant, success rate (83 versus 77%) with retrograde endopyelotomy, which was 37% more cost-effective. Complication rates were higher with antegrade compared to retrograde endopyelotomy for primary and secondary ureteropelvic junction obstruction (25 versus 14% and 26 versus 0%). In 20 patients with concomitant stones endopyelotomy results were better (93 to 100% success) than for any other categories of ureteropelvic junction obstruction. Of note, endopyelotomy also provided a reasonable outcome among patients with a high insertion primary ureteropelvic junction obstruction (70% success)., Conclusions: Antegrade endopyelotomy is the preferred approach in patients with primary ureteropelvic junction obstruction and concomitant renal calculi (13.4% of cases), and may also be preferable in patients with high insertion obstruction (6.7%). For all other primary and all secondary ureteropelvic junction obstruction, antegrade and retrograde endopyelotomy is effective therapy yet retrograde endopyelotomy results in less operating room time, shorter hospital stay, fewer complications and significantly less expense to achieve the desired outcome.

The greatest difficulty in performing a laparoscopic pyeloplasty is the suturing of the ureteropelvic junction. The purpose of this study was to evaluate the use of nonperforating titanium vascular closure staple (VCS) clips to perform in laparoscopic ureteroureterostomy in the porcine model. Six female minipigs underwent laparoscopic transection of one of the proximal ureters at the level of the lower pole of the kidney. Ureteroureterostomy was then performed using the titanium VCS clips. The animals were evaluated at 6 and 12 weeks postureteroureterostomy with retrograde pyelography and differential creatinine clearances. At 12 weeks, the animals were euthanized, and the area of ureteroureterostomy was examined grossly and histopathologically. The technique for laparoscopic vascular clipping of the ureteroureterostomy proved to be fast and effective. Follow-up indicated that the method was successful in producing a functionally patent anastomosis. No encrustation, stone formation, or intraluminal clip was noted in any of the ureters or kidneys undergoing the ureteroureterostomy. The area of the ureteroureterostomy showed minimal fibrosis and inflammation on histopathologic examination. In this animal study, the nonperforating titanium clips facilitated the performance of a laparoscopic ureteroureterostomy.

Laparoscopic radical nephrectomy (LRN) for renal-cell carcinoma (RCF) with removal of the specimen by morcellation and suction remains controversial because precise pathologic tumor staging is lost, and there is a risk of tumor seeding. We assessed the theoretical impact of surrendering precise pathologic staging on the management of patients with low-stage RCC (T3a or less). In 22 patients who underwent open radical nephrectomy for RCC, the preoperative CT-based clinical stage was correlated with pathologic tumor staging. Possible clinical inclusion criteria for LRN were then correlated with pathologic tumor staging. When comparing clinical and pathologic staging, one patient was understaged and seven were overstaged by preoperative CT. However, if clinical stage T3a or lower was used as the inclusion criterion for LRN, 19 patients (86%) would have been so treated, none would have been underassigned, and future management would not have been compromised according to pathologic staging. Management of patients with low-stage RCC relying on clinical staging only is oncologically adequate. This would make LRN an acceptable option for this subset of patients.

We assessed the results of endourologic treatment of patients with a primary ureteropelvic junction obstruction (UPJO) caused by high insertion of the ureter into the renal pelvis (HIUPJO). A total of 10 patients 15 to 76 years old with preoperatively diagnosed HIUPJO were treated. Acucise retrograde endopyelotomy was performed in eight patients and percutaneous antegrade endopyelotomy in two. A stent was left in place for an average of 5.3 weeks. The subjective success rate, based on patient questionnaire and analog pain scales, was 80% at 27 months' average follow-up. The objective success rate, based on diuretic renal scanning or Whitaker test, was 70% at 26 months' mean follow-up. Overall, 60% of the patients had both an objectively and a subjectively successful outcome. The success rate for endopyelotomy in patients with UPJO caused by high insertion is similar to that reported for endopyelotomy in patients without high insertion. High insertion is not a contraindication to endopyelotomy.

Endopyelotomy for secondary ureteropelvic junction obstruction (UPJO) is a highly effective procedure. However, the impact of the etiology of the obstruction on the outcome of an endopyelotomy has not been defined. Herein, we review the success rates with endopyelotomy for secondary UPJO after failure of open pyeloplasty or endopyelotomy. Thirty-five adult patients with both objective and subjective follow-up were identified retrospectively who had endopyelotomy for secondary UPJO. Twenty-four patients had failed a previous open reconstruction (23) or laparoscopic Foley Y-V plasty (1). Eleven patients had failed a prior endopyelotomy. Retrograde endopyelotomy was performed using the Acucise device in 11 patients, and antegrade endopyelotomy was performed in 24 patients. Objective follow-up was obtained with diuretic renal scintigraphy (mean 14.1 months) and subjective follow-up by analog pain scales (mean 27.8 months). Objective success was defined as no obstruction on renal scintigraphy, while subjective success was used to describe a minimum of 50% resolution of symptoms. The subjective success rate of secondary endopyelotomy in the open-pyeloplasty group was 88% v 71% in the prior endopyelotomy group (P = 0.20). The objective success rate in the failed-pyeloplasty group was 71% v 55% in the prior endopyelotomy group (P = 0.40). Endopyelotomy for secondary UPJO has a good success rate. Success rates tend to be higher in patients who have failed an open pyeloplasty; however, a statistically significant difference was not seen between the two groups.

Spatial anatomy of the lower renal pole, as defined by the infundibulopelvic angle (LIP angle), infundibular length (IL), and infundibular width (IW), plays a significant role in the stone-free rate after shockwave lithotripsy. A wide LIP angle, a short IL, and a broad IW, individually or in combination, favor stone clearance, whereas a LIP <70 degrees, an IL >3 cm, or an IW < or =5 mm are individually unfavorable. When all three unfavorable factors or an unfavorable LIP and IL coexist, the post-SWL stone-free rate falls to 50% or less. Using these criteria, more than one fourth of our patients with a lower-pole calculus might have been better served by an initial percutaneous or perhaps ureteroscopic procedure, neither of which is significantly affected by the lower-pole spatial anatomy.

Purpose: We evaluate and compare the characteristics and drawbacks of different synthetic and organic materials that have been used for bladder wall replacement., Materials and Methods: We extensively reviewed the contemporary literature for partial bladder wall replacement with synthetic or organic materials., Results: The concept of bladder wall replacement dates back to the early nineteenth century. Based on the unique regenerative capability of the bladder, many organic and synthetic allografts and xenografts were implanted in the bladder wall with a wide range of outcomes. Recently, various biodegradable allografts have been developed and used successfully in animal models. Despite the favorable animal results, only a few of the materials have been used clinically for bladder wall replacement to date., Conclusions: Further improvements in the use of existing materials and development of new materials will hopefully result in clinically successful grafts for bladder wall replacement and for whole bladder substitution.

Purpose: We determine whether there is a significant relationship between the spatial anatomy of the lower pole, as seen on preoperative excretory urography (IVP), and the outcome after shock wave lithotripsy or ureteroscopy for a solitary lower pole caliceal stone 15 mm. or less., Materials and Methods: Between January 1992 and June 1996, 34 patients with 15 mm. or less solitary lower pole stone underwent ureteroscopy with intracorporeal lithotripsy (13) or extracorporeal shock wave lithotripsy (ESWL) with a Dornier HM3 lithotriptor (21). On pretreatment IVP lower pole infundibular length and width, infundibulopelvic angle of the stone bearing calix were measured. Stone size and area were determined from an abdominal plain x-ray. A plain x-ray of the kidneys, ureters and bladder was obtained in all patients at a median followup of 12.3 and 8 months in the ureteroscopy and ESWL groups, respectively., Results: After initial therapy the overall stone-free rate was 62 and 52% in the ureteroscopy and ESWL groups, respectively. Stone-free status after ESWL was significantly related to each anatomical measurement. Infundibulopelvic angle 90 degrees or greater, and infundibular length less than 3 cm. and width greater than 5 mm. were each noted to correlate with an improved stone-free rate after ESWL. In contrast, the stone-free rate after ureteroscopy was not statistically significantly impacted by these anatomical features, although a clinical stone-free trend was identified relating to a favorable infundibular length and infundibulopelvic angle. The infundibulopelvic angle was 90 degrees or greater in 4 stone-free patients (12% overall), including 2 who underwent ureteroscopy and 2 who underwent ESWL. On the other hand, in 2 and 4 stone-free patients (18% overall) who underwent ureteroscopy and ESWL, respectively, favorable radiographic features consisted of a short, wide but acutely angulated infundibulum with the infundibulopelvic angle less than 90 degrees, and infundibular length less than 3 cm. and width 5 mm. or greater. In contrast, in 4 and 6 patients (29% overall) who underwent ureteroscopy and ESWL, respectively, all 3 radiographic features were unfavorable with the infundibulopelvic angle less than 90 degrees, and infundibular length greater than 3 cm. and width less than 5 mm. In these cases the stone-free rate was 50 and 17% after ureteroscopy and ESWL, respectively., Conclusions: The 3 major radiographic features of the lower pole calix (infundibulopelvic angle, and infundibular length and width) can be easily measured on standard IVP using a ruler and protractor. Each factor individually has a statistically significant influence on stone clearance after ESWL. A wide infundibulopelvic angle or short infundibular length and broad infundibular width regardless of infundibulopelvic angle are significant favorable factors for stone clearance following ESWL. Conversely, these factors have a cumulatively negative effect on the stone clearance rate after ESWL when they are all unfavorable. In ureteroscopy spatial anatomy has less of a role in regard to stone clearance but it may have a negative impact when there is uniformly unfavorable anatomy.

Vesicoureteral reflux (VUR) in the animal model for experimental purposes can be created either by open transvesical or endoscopic techniques. The concept of reflux creation is the same for both techniques: incision of the roof of the intramural portion of the ureter at the 12 o'clock position. The open method has the disadvantages of requiring a cystotomy and a lengthy healing period prior to initiating a study, thereby incurring additional expense and the problem of introducing several confounding factors. The open method is unreliable because of the resolution of reflux over time. Herein, we present a simple transurethral endoscopic technique for creating VUR in pigs. This technique was successful in producing persistent Grade II or III reflux in 94% of the incised ureters.