Training the resident in percutaneous nephrolithotomy

Objective: From the trainers\u27 perspective percutaneous nephrolithotomy (PCNL) is one of the most challenging endourological procedures. In this review we examine the problems arising when training residents in PCNL, and how to facilitate this process. Methods: The recommendations are derived from discussions and consensus during the First European Urolithiasis Society (EULIS) meeting held in London in September 2011. In addition, we searched Medline for articles identified using the keywords \u27training\u27, \u27percutaneous surgery\u27, \u27renal calculi\u27, \u27PCNL\u27, \u27virtual reality\u27 and \u27simulators\u27. We also assessed the effect of modern technology, including the availability of virtual reality models vs. operating room training, and how international organisations like EULIS and European Urological Association can help. Results: The difficulty of training residents in PCNL is partly due to the complexity of obtaining a safe access to the kidney for lithotripsy. The most common way of obtaining access is guided by imaging only, and usually only fluoroscopic imaging is available. This has the potential for injuring structures from the skin to the renal capsule. Minor vascular injuries are relatively common, although most are self-limiting. Visceral injuries that are particularly important are pleural and less commonly colonic injuries, but they are more complex and often require additional procedures. Conclusions: Teaching the skills is more challenging than performing PCNL. In most urological training programmes it is difficult to incorporate teaching and training skills when performing PCNL. To train an academic stone doctor, proficiency in the safe conduct of PCNL is mandatory

Short report. The AIDIT and IMPACT conference 2006: Outcomes and future directions

IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls) is an international collaboration investigating the utility of targeted prostate-specific antigen (PSA) screening for men at increased risk of prostate cancer due to inherited predisposition. Although the majority of prostate cancer occurs sporadically, it is recognized that family history plays a role in a significant number of cases: a family history either of prostate cancer alone, or of other cancers including breast and ovarian cancer. Evidence of the link between single genes and prostate cancer risk is strongest for the BRCA1 and BRCA2 genes, with BRCA2 in particular thought to lead to a relative risk of 4.65 (95%CI 3.48-6.22). This relative risk may be as high as 7.33 in men under the age of 65 years

Does Imaging Modality Used for Percutaneous Renal Access Make a Difference? A Matched Case Analysis

Objective: To assess perioperative outcomes of percutaneous nephrolithotomy (PCNL) using ultrasound or fluoroscopic guidance for percutaneous access. Methods: A prospectively collected international Clinical Research Office of the Endourological Society (CROES) database containing 5806 patients treated with PCNL was used for the study. Patients were divided into two groups based on the methods of percutaneous access: ultrasound versus fluoroscopy. Patient characteristics, operative data, and postoperative outcomes were compared. Results: Percutaneous access was obtained using ultrasound guidance only in 453 patients (13.7%) and fluoroscopic guidance only in 2853 patients (86.3%). Comparisons were performed on a matched sample with 453 patients in each group. Frequency and pattern of Clavien complications did not differ between groups (p = 0.333). However, postoperative hemorrhage and transfusions were significantly higher in the fluoroscopy group: 6.0 v 13.1% (p = 0.001) and 3.8 v 11.1% (p = 0.001), respectively. The mean access sheath size was significantly greater in the fluoroscopy group (22.6 v 29.5F; p = 27F) and multiple punctures. Prospective randomized trials are needed to clarify this issue

Psychosocial impact of undergoing prostate cancer screening for men with BRCA1 or BRCA2 mutations.

OBJECTIVES: To report the baseline results of a longitudinal psychosocial study that forms part of the IMPACT study, a multi-national investigation of targeted prostate cancer (PCa) screening among men with a known pathogenic germline mutation in the BRCA1 or BRCA2 genes. PARTICPANTS AND METHODS: Men enrolled in the IMPACT study were invited to complete a questionnaire at collaborating sites prior to each annual screening visit. The questionnaire included sociodemographic characteristics and the following measures: the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), 36-item short-form health survey (SF-36), Memorial Anxiety Scale for Prostate Cancer, Cancer Worry Scale-Revised, risk perception and knowledge. The results of the baseline questionnaire are presented. RESULTS: A total of 432 men completed questionnaires: 98 and 160 had mutations in BRCA1 and BRCA2 genes, respectively, and 174 were controls (familial mutation negative). Participants' perception of PCa risk was influenced by genetic status. Knowledge levels were high and unrelated to genetic status. Mean scores for the HADS and SF-36 were within reported general population norms and mean IES scores were within normal range. IES mean intrusion and avoidance scores were significantly higher in BRCA1/BRCA2 carriers than in controls and were higher in men with increased PCa risk perception. At the multivariate level, risk perception contributed more significantly to variance in IES scores than genetic status. CONCLUSION: This is the first study to report the psychosocial profile of men with BRCA1/BRCA2 mutations undergoing PCa screening. No clinically concerning levels of general or cancer-specific distress or poor quality of life were detected in the cohort as a whole. A small subset of participants reported higher levels of distress, suggesting the need for healthcare professionals offering PCa screening to identify these risk factors and offer additional information and support to men seeking PCa screening

Percutaneous nephrolithotomy in children in different age groups

INTRODUCTION & OBJECTIVES: To present the overall results of pediatric percutaneous nephrolithotomy (PCNL) in addition to the indications, complications and outcomes according to the different age groups treated in the participating centers in the PCNL Global Study. MATERIAL & METHODS: The Clinical Research Office of the Endourological Society (CROES) study was conducted between November 2007 and December 2009, including 96 centers and more than 5800 patients. All children aged 14 years and under in the PCNL Global Study database are the focus of the study. After a general evaluation of PCNL results in children, cases were further divided into three age categories based on the World Health Organization classification as: Infants ( 641 year), young children (2-4 years) and school-age children (5-14 years). For the purpose of comparison of PCNL results between adults and children, patients were divided as 0- 14 years of age and 15 years and older. RESULTS: One hundred seven children aged 14 years and younger were included in the analysis. A considerable number (45.7%) of patients had a previous history of stone intervention. PCNL procedure was conducted in 13 patients (12.1%) in the supine position, 15 patients (14%) had tubeless PCNL, and in 22 patients (20.5%) balloon dilatation was preferred. Overall mean operation time was 97.02 min; blood transfusion rate, fever and stone free rates were 9%, 14% and 70.1%, respectively. In the comparison of adult and pediatric cases, preoperative positive urine culture was higher in the adult group (p=0.014). While a considerable percentage of adult patients had comorbidities, one child had cardiovascular disease. In operative details, mean dilatation method, mean sheath size, mean nephrostomy tube size, and methods for confirming stone-free status were different between children and adults; however, the surgical outcomes were comparable. On categorizing the pediatric PCNL cases according to age groups, no statistically significant differences were found among the subgroups with regard to patient characteristics, co-morbidities, renal anomalies, or previous surgical history. In the evaluation of the operative details, mean sheath size and nephrostomy tube size were larger in school-age children compared to the preschool children (p=0.01 and 0.002, respectively). There was a difference in the preferred methods for confirming stone-free status, with ultrasonography preferred more in preschool children (p=0.0002). The PCNL procedure position, puncture site, dilatation method, postoperative tube application, and surgical outcomes were comparable in school- and preschool- age children. CONCLUSIONS: Based on the findings of the present study, we can suggest that PCNL can be applied safely and effectively in children of all ages, including infants. Outcomes appear comparable with those in adults with respect to the success and complication rates, provided that substantial indications, equipment and experience are present

Consultation on UTUC, Stockholm 2018: aspects of treatment

Purpose: To provide an overview of treatment modalities for management of upper tract urothelial carcinoma (UTUC). Methods: In accordance with the standards for a scoping review, data presentation and discussion at the Consultation on UTUC in Stockholm, 6–7 September 2018, consensus was reached on the latest and most important treatment recommendations for UTUC. Using Pubmed, Web of Science, and Embase, publications were selected based on quality, clinical relevance, and level of evidence. Results: Kidney-sparing surgery should be attempted for low-grade UTUC. Radical nephroureterectomy with bladder cuff excision is first option for high-grade disease. Post-operative bladder instillation of chemotherapy should be offered after RNU to reduce intravesical recurrence rate. Identification of tumor grade and stage is crucial when selecting treatment. Ureteroscopic management of low-grade and non-invasive UTUC achieves disease-free survival similar to that offered by radical nephroureterectomy but seems to be a risk factor for intravesical recurrence. Lymphadenectomy appears important for high-risk disease, although the therapeutic benefit needs further validation. There is little evidence supporting use of Bacillus Calmette–Guérin (BCG) and mitomycin C as monotherapy and adjuvant treatment in UTUC. A randomized clinical trial has indicated that platin-based chemotherapy for invasive UTUC improves disease-free survival, suggesting that adjuvant chemotherapy should be considered standard care for ≥ T2 N0–3M0 disease. Conclusions: Risk stratification assessment is feasible and mandatory in UTUC. Identification of tumor grade and stage is essential for optimal treatment selection. Kidney-sparing surgery should be offered in low-risk disease, whereas radical nephroureterectomy and adjuvant chemotherapy should be considered in high-risk disease