Introduction & Objective:
Surgeon-reported outcomes have been the main measures in reporting surgical results. An emerging paradigm to assess patients’ experience from the qualitative aspect has increased the interest in Patient-Reported Outcome Measures (PROMs). The primary stages of generating and selecting items for our renal stone disease-specific PROM via focus groups and semi-structured interviews were presented previously. Our aim is establishing the test-retest reliability and internal consistency of the developed renal stone disease-specific PROM.

Methods:
In a pilot study, patients with radiologically proven renal calculi presenting to our stone clinic were invited to participate in test-retest of our developed renal stone disease-specific PROM along with demographic and clinical data.

Results:
Analysis was performed to determine internal consistency within domains using Cronbach’s alpha with a mean of 0.91 (range 0.89 to 0.93) and Cronbach’s alpha between domains was 0.93. Average inter-item Pearson’s and Spearman’s correlation with in domains was performed, with Pearson’s correlation mean of 0.78 (range 0.73 to 0.86) and Spearman’s correlation mean of 0.73 (range 0.66 to 0.76). Test-retest Pearson’s correlation mean was 0.84 (range 0.51 to 0.95). Bland-Altman analysis was conducted for all domains, the overall mean of differences is 0.10 and 95% limits of agreement were between -1.05 & 1.25.

Conclusions:
After excluding redundant questions, test-retest reliability, internal consistency within domains and average inter-item correlation within domains were high. We will now evaluate renal calculi therapy prospectively using our renal stone disease-specific PROM, in addition to establishing the construct validity together with the EQ-5D-5L and criterion validity.

OBJECTIVES: Post chemotherapy retroperitoneal lymph node dissection (RPLND) in patients with metastatic nonseminomatous germ cell tumours with residual lymph nodes offers a staging benefit and a therapeutic benefit for excision of chemoresistant tumours (e.g Teratoma, sarcoma). Traditionally RPLND is performed through an open approach. We aim to assess the feasibility and complications of laparoscopic RPLND (LRPLND).
PATIENTS AND METHODS: A retrospective review of the medical records of 29 consecutive patients who underwent postchemotherapy LRPLND by a single surgeon from April 2013 to January 2017 was performed. Operative details, post operative morbidity and histologic findings were assessed.
RESULTS: The mean size of residual disease in the retroperitoneum in preoperative scans was 2.6 cm (range 0.8-6.2 cm). The surgical technique consisted of a transperitoneal laparoscopic excision of a unilateral modified template (left template in 17, right in 12 patients). There was one conversion due to failure to progress. Mean operative time was 160 minutes (range 90-240 min). Mean post operative drop in haemaoglobin was1.1 g/dL. Postoperative complications were lymphocele in two patients managed conservatively and one postoperative pyrexia. Mean hospital stay was 1.5 days (range 1-3 d). Histology showed mature teratoma in 16 patients (55%), active tumour in 5 (17%) and necrosis or fibrosis in 8 patients (28%).Mean number of lymph nodes removed was 9 (range 1-20).During a mean follow-up of 23 months one patient with undifferentiated teratoma had recurrence.
CONCLUSIONS: LRPLND is is feasible and effective procedure in experienced hands. Further studies are needed to precisely clarify oncological outcomes.

Introduction

Surgery facilitates cancer progression via the immunosuppressive effects of the surgical stress response, dispersion of micro-metastases, and VEGF-mediated angiogenesis1.
Regional anaesthesia inhibits this surgical stress response, reduces pain, and has a direct anti-cancer effect2.
The aim of this study is to ascertain whether there is any difference in cancer recurrence rates in patients undergoing radical nephrectomy for renal cell carcinoma receiving epidural analgesia plus a general anaesthetic, compared to general anaesthesia alone.

Method

We prospectively collected single surgeon/single centre data over 12 years, and divided patients into two groups; those with a peri-operative epidural, and those without. We compare time to radiologically detected recurrence during standard follow-up. We consider surgical tumour characteristics and blood transfusion rates to identify any significant confounders.


Results

We included 471 patients; 193 in the epidural group, and 278 in the non-epidural group. Demographics in table 1, Recurrence rates table 2. There were 44 cases of recurrence in the epidural group [23%]; versus 76 cases of recurrence in the non-epidural group [27.3%]; Sub-hazard ratio (SHR) of 0.53 (95% CI 0.24 - 1.09, p 0.08). Mean time to recurrence was 12.8 months in the epidural group, versus 17.1 months in the non-epidural group. SHR for blood transfusion was 0.82 (95% 0.18 - 3.7).

Discussion

There is a reduced cancer recurrence rate in the epidural group, SHR 0.53,that approaches significance, We believe epidural anaesthesia may be protective against renal cancer recurrence; however, larger, national data sets are needed to support this work.

Introduction
Our objective was to investigate whether patients with small asymptomatic distal ureteric calculi require follow-up imaging to confirm stone passage.

Patients and Methods
Patients were identified from a prospective database of all new cases of urolithiasis presenting in a UK teaching hospital over an 18 month period from January 2015 to June 2016. Those who had a computer-tomography (CT) confirmed calculus in the distal ureter of 5mm or less were included.

Results
914 cases were added to our database over the study period, of which 192 patients met study inclusion criteria. 167 patients were managed conservatively. 138 attended for follow-up over a mean time period of 5.38 weeks (SD=3.46). At follow-up, 107 patients had no evidence of stone passage. 20 were symptomatic and a majority of 18 had a follow-up CT. Persistent calculus was demonstrated on three. The remaining two patients had radiographs; neither showed a calculus
87 patients were asymptomatic at follow-up, of which 53 underwent a limited non-contrast pelvic CT. Four (7.5%) had not passed the calculus. The mean time between initial and follow-up CT was 10.66 weeks (SD=7.35). 25 cases had no further imaging, none have re-presented. Of the remaining patients six had ultrasound and three had radiograph follow up. Persistent calculus was seen on one radiograph.

Conclusion
Despite study limitations the detection rate of 7.5% is important when considering follow-up in asymptomatic patients with small distal ureteric calculi . The drawbacks of repeated imaging need to be weighed against the risks of undetected calculi.

Introduction

Previous abdominal surgery is thought to increase risk of complications in subsequent laparoscopic procedures. We examined the technical feasibility and immediate outcomes of laparoscopic nephrectomy in such patients, investigating whether surgical history is an added risk factor.

Patients and Methods

408 patients underwent laparoscopic nephrectomy at our institution by a single surgeon(June 2013 - April 2017). Patients with previous surgical history (Group A) were compared to those without (Group B). Procedure duration, blood loss(EBL), warm ischaemia time, peri-operative complications and length of stay(LOS) were compared. Further subgroup analysis examined the impact of previous upper or lower abdominal surgery. Data was retrieved from a prospectively maintained database.

Results

There was no significant difference in procedure time, ischaemia time, EBL, transfusion or complication rates between groups. Open conversion rates were similar: 2.1% vs 2.5%(p=0.8).
Although the Clavien-Dindo severity of complications was similar across groups (p=0.9), Group A had longer overall LOS (mean 3.6 vs 2.8 days, p=0.02).


Conclusion

In our group, previous surgery did not significantly increase peri-operative risks for laparoscopic nephrectomy. The marginally longer LOS noted is to be expected in an older patient group, with known previous comorbidities.

Introduction

We reviewed the impact of surgical indication for laparoscopic nephrectomy in a young population, on the perioperative course to investigate whether donor nephrectomy patients fare differently from their pathological counterparts.

Patients and Methods

110 patients (<40years) underwent laparoscopic nephrectomy between June 2009 and April 2017 at our institution by a single surgeon. Data was retrieved from a prospectively maintained database.

Length of procedure, estimated blood loss (EBL), perioperative complications and length of stay (LOS) was compared between the Donor group and Non-donor group.

Results

There were no significant differences in the immediate perioperative outcomes between groups. Overall intraoperative complication rate was 3.8%, with 3 open conversions (including 1 donor) and one case requiring transfusion. EBL>500ml was seen in 2.6% and 4.5% of donor and non-donor cases respectively(p=0.6).13.5% cases developed a post-operative complication, with either group having one patient with a Clavien-Dindo score≥3.

However, LOS was longer in donor cases (Median 3 vs 2days, p=0.004) with 66% staying beyond 2 days compared to 32% for pathological cases (p=0.01).

Conclusion

In our experience, undergoing donor nephrectomy does not mitigate the perioperative course. The longer post-operative stay we noted may stem from the healthy patient’s expectation of returning to a high normal baseline prior to discharge. Further data is needed on the short and medium term recovery.

Patients with distal renal tubular acidosis (dRTA) are at a high risk of brushite kidney stone formation and recurrence because of increased calcium phosphate tubular excretion, reduced citrate excretion and increased urinary pH. Previous studies have shown a high prevalence of dRTA among hypercalciuric stone formers. The aim of this study was to compare the biochemistry of hypercalciuric stone formers with and without dRTA to assess if there are any suitable baseline screening indicators that may predict patients with dRTA.

Patients with recurrent urolithiasis and hypercalciuria were reviewed in metabolic stone clinic. Baseline serum and 24hr-urine biochemistry was recorded. All patients underwent a furosemide acidification test. Patients were then split into two cohorts: dRTA (failure to acidify urine pH <5.5) and non-dRTA. Baseline biochemical parameters were compared between the two groups using the Mann Whitney-U test.

Of a total of 43 patients, 84% were male, average age was 58. Nine patients (21%) had dRTA based on the furosemide acidification test. Urine pH was higher in the dRTA group (6.6vs5.7, p=0.005) and serum bicarbonate was lower (23.4mM vs 25.9mM, p=0.0001). Otherwise, there was no significant difference in baseline biochemistry.

As expected, patients with dRTA had a higher baseline urinary pH and lower serum bicarbonate. However, we have found no evidence that any additional urine or serum biochemical markers would be useful indicators to prompt dRTA testing. We therefore suggest testing for dRTA in all hypercalciuric patients with recurrent urolithiasis, or calcium phosphate stones, in order to optimise further biochemical management.

Introduction

As a rare disease, cystinuric patients have little opportunity to meet other patients affected by the disease. The key to ensuring self-management is empowerment through information and education. Websites and social media groups are some of the ways of disseminating this information. Patient information days offer the opportunity for patients and family members to meet each other, share stories and management strategies while also meeting health care professionals.

Method

We organised a national free to attend patient support day with the National Registry of Rare Kidney Diseases (RaDaR) group; allowing patients and their families to network and gain knowledge and advice about their condition. Interactive lectures were given on surgical, nephrological, research and dietetic topics. Selected patients shared their stories with the group. Small breakout sessions allowed interaction and sharing of information. Patients were given feedback questionnaires to objectively collect data.

Results

Sixty-four people attended the day. Twenty-three patients (male 11, female 12) with their families completed the survey. A broad range of ages (18- 70) were represented. 50% of attendees (11) had attended a similar event in the past. The majority (78%) of patients felt the day met their expectations and 96% would recommend the event to others. Apart from the usefulness of the update sessions, patient’s found listening to other patient stories useful (96%) and enjoyable (83%).

Conclusion

Patient information days are useful and a valuable source of information and networking opportunities. Future days will include more patient stories and dietary advice based on the feedback obtained.

Introduction and Objectives
Side effects of morphine may prolong post-operative recovery and length of hospital stay (LOS)1. Local anaesthetic wound infusion systems (LAIS) reduce LOS and pain after open surgery2. Literature search shows no evidence of LAIS use following laparoscopic surgery. We assessed LAIS use in patients after laparoscopic nephrectomy (LN) and laparoscopic nephrourectomy (LNU) compared with morphine via patient controlled analgesia (PCA).

Methods
A retrospective series of LN or LNU patients from 2014-2017 were divided into two groups; LAIS (ON-Q* Pain Relief System) with continuous infusion of 0.125% Bupivacaine vs. PCA post-operatively. Both groups used paracetamol, and additional analgesia (morphine, tramadol, codeine) post-operatively. All PCAs and LAIS were removed day1 post-operatively. Primary outcomes were post-operative opiate analgesia used (morphine, tramadol, codeine) and LOS. Mann-Whitney U test was used for statistical analysis.

Results
32 patients underwent LN or LNU; 16 with LAIS vs. 16 with PCA post-operatively. Patient demographics were similar between groups, median age(p=0.465), BMI(p=0.250) and comorbidities(p=0.928). No statistical difference in intra-operative opiate use(p=0.112) and post-operative weak opiate (tramadol, codeine) requirements(p=0.459).

Median morphine per 24 hours was 26.7mg and 3.3mg in PCA and LAIS group respectively. This was statistically significant(p=0.00014). LOS in the PCA vs. LAIS group were significantly different (median LOS 2.5 vs. 1 day), (p=0.00634).

Conclusions
There was a significant reduction in post-operative morphine and LOS following LN or LNU with PCA vs. LAIS use. LAIS should be considered a first-line treatment after laparoscopic surgery as patients do not require in-hospital monitoring, therefore, expediting discharge from hospital.

Introduction: Ureteric stenting is a common procedure in urology. Current literature suggests that the preconceived idea that stenting with the string in situ causes more patient discomfort and increases the risk of infection are actually unfounded. We believe leaving the string in situ reduces dwell time and costs associated with removal. Our aim was to elicit what proportion of urologists are leaving the string in situ and if they are not, then exploring the reasons behind it.
Methods: We used 9 questions via SurveyMonkey to document current practice following completed uncomplicated ureteroscopic procedures. We sent this to all consultant urologists in the South West region.
Results: We received 26 responses from 8 centres, 50% of which are stone specialists. 42% never use the string while the remainder do so in a proportion of cases (median 80%). Determining factors include: patient gender (10%), patient symptoms (5%) and patient preference (29%). Removing the string increases planned dwell time from a median of 3-7 days to a median of 14 days. The reasons given for not leaving the string in situ are fear of stent dislodgement (47%), patient reluctance (21%) and no prior experience (37%). Only 40% were aware of the literature.
Conclusion: A significant proportion of the South West urologists are not utilising the stent strings following uncomplicated completed ureteroscopy and are unaware of the literature. We aim to educate and encourage the use of strings.

Introduction and Objective
It is well known that renal stone disease is a recurrent condition with up to 50% of patients having repeated episodes within 5 to 10 years. International guidelines suggest performing stone analysis for the comprehensive evaluation of patients with urinary tract calculi and it plays a very important role in the long-term management of this condition.

Methods
We retrospectively reviewed all the urinary tract calculi submitted to the Department of Chemical Pathology and Metabolic Diseases at the University Hospitals of Leicester, UK, over a 5-year period between 2010 and 2015. Samples were received from England, Scotland, Wales, Northern Ireland and the Republic of Ireland. All specimens were analysed using state-of-the-art infrared spectroscopy for major, minor and trace components.

Results
A total of 5,753 specimens were received of which 5533 (96.2%) were adults and 220 (3.8%) were from paediatric patients.

In pediatric patients, there were 143 males and 77 females (M:F = 1.9:1) with a median age of 9 years (0-17 years). The most prevalent stones were calcium phosphate stones (38.6%), followed by calcium oxalate (32.7%), struvite (12.3%), cystine (7.3%), urate (3.2%) and small numbers of other compositions such cholesterol stones.

In the adult cohort there were 3,873 male and 1,660 female specimens (M:F = 2.3:1) with a median age of 56 years (18-97). Calcium oxalate stones were the most prevalent (62.1%), followed by calcium phosphate (19.8%), urate (10.1%), struvite (4.3%) and cystine (0.9%). Small quantities of rarer stones were also identified such as cholesterol, sulphate, xanthine and quartz stones (0.23%).

Discussion
This is the largest pediatric stone analysis database in Europe. Calcium oxalate crystals appears to be the most prevalent stones (ranging from 36-78%) in the majority of the published literature from USA, Europe and Africa [1,2,3,4]. It is interesting to note that in our study the most prevalent crystal was calcium phosphate. It is unclear if this is due to consumed local water content or variations in dietary and lifestyle choices.

This is also the largest adult stone analysis database in the UK and one of the largest in Europe. The most prevalent major stone composition in our study was calcium oxalate, and compared to other published literature [5,6,7,8] our prevalence, is comparable (45-81% in these studies).

This study provides valuable contemporary insight into the most common major composition of urinary tract calculi in our local population and can help to address risk factors accordingly.