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author:("andosan, Sero")
1.  Bone mineral density status in urolithiasis patients with vitamin D inadequacy followed at a tertiary stone centre 
We assessed abnormalities in bone mineral density (BMD) and the risk of hip and major osteoporotic fractures in urolithiasis patients with vitamin D inadequacy (VDI) followed at a tertiary stone centre.
Stone-free patients with VDI were invited to undergo dual-energy x-ray absorptiometry (DXA) scans to assess for BMD abnormalities at the femoral neck and lumbar spine. The World Health Organization’s validated Fracture Risk Assessment Tool (FRAX) was used to calculate the risk of hip and major osteoporotic fractures within 10 years. Patients with primary hyperparathyroidism or hypercalcemia were excluded.
In total, 50 consecutive patients were included between June 2011 and August 2012, including 26 (52%) males. The median age was 51 years and the median 25-hydroxyl vitamin D (25[OH] D) was 18.8 ng/mL. Thirty patients (60%) had abnormal T-scores on DXA studies. This decreased to 22 (44%) when age-matched Z-scores were used; 36% had osteopenia and 8% had osteoporosis. Femoral neck and lumbar spines were affected in 24% and 32% of patients, respectively. Recurrent stone-formers had significantly lower BMD when compared with first-time stone formers. Median serum 25(OH)D was comparable between patients with normal and abnormal DXA scans (18.6 vs. 18.8 ng/mL; p = 0.91). Five patients (10%) were at high risk (≥3%) of hip fractures within 10 years.
A high prevalence of abnormal DXA scans was found in urolithiasis patients with VDI, including 5 patients (10%) at high risk of hip fractures. Future studies need to assess the economic impact of obtaining DXA scans on urolithiasis patients with VDI, especially in recurrent stone-formers.
PMCID: PMC4216288  PMID: 25408797
2.  Long-term incidence of symptomatic urolithiasis post-bariatric surgery 
Canadian Urological Association Journal  2014;8(9-10):E688-E694.
The risk of urolithiasis post-Roux-en-Y gastric bypass (RYGB) surgery is higher when compared to the general population. Calcium and vitamin D supplementation is routinely prescribed to these patients, yet compliance with these supplements is unknown. The aim of this study was to assess the incidence of symptomatic de novo urolithiasis post-RYGB and compliance with calcium and vitamin D supplementation.
A standardized telephone questionnaire was administered to patients who underwent RYGB between 1996 and 2011. Personal and medical histories were obtained with emphasis on episodes of symptomatic urolithiasis and calcium and vitamin D supplementation.
The response rate was 48% with 478 patients completing the telephone questionnaire. After a mean follow-up of 7.0 years (range: 1–15), the incidence of post-RYGB symptomatic urolithiasis was 7.3%, while the rate of de novo symptomatic urolithiasis was 5%. The overall median time to present with symptomatic urolithiasis was 3.1 years, with 3.3 years for de novo stone-formers, and 2.0 years for recurrent stone-formers (p = 0.38). In de novo stone-formers, 33% presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with calcium and vitamin D supplementation was 56% and 51%, respectively.
Despite recall bias and lack of confirmatory imaging studies, a high postoperative incidence of symptomatic urolithiasis was found in a large sample of post-RYGB patients. A third of patients with de novo stones, presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with postoperative calcium and vitamin D supplementation was poor and needs improvement.
PMCID: PMC4216300  PMID: 25408808
3.  Are stone analysis results different with repeated sampling? 
We assessed differences in results of stone analyses on subsequent sampling.
A retrospective review of patients with stone analyses at a tertiary stone centre between March 2006 and July 2012 was performed. All stones were analyzed at a centralized laboratory using infrared spectroscopy. Patients were grouped according to the first predominant stone type on record, as defined by the predominant stone component of at least 60%. Stone groups included calcium oxalate (CaOx), calcium phosphate (CaP), uric acid (UA), cystine, struvite, mixed CaOx-CaP and mixed CaOx-UA. All patients had a full metabolic stone workup.
Of the 303 patients with stone analyses, 118 (38.9%) patients had multiple stone analyses. The mean age was 53.4 ± 15.1 years, and 87 (73.7%) were males. Of the 118, the initial stone analysis showed 43 CaOx, 38 CaP, 21 UA, 4 CaOx-CaP, 2 CaOx-UA, 6 cystine, and 4 struvite. There was a different stone composition in 25 (21.2%) patients with a median time delay of 64.5 days. Different compositions were found in 7 CaOx (to 3 CaP, 2 CaOx-CaP, and 2 UA), 5 CaP (to 3 CaOx and 2 CaOx-CaP), 3 UA (to 3 CaOx), 4 CaOx-CaP (to 2CaOx, 1 UA and 1 CaP), 2 CaOx-UA (to 2 CaOx) and 4 struvite (to 3 CaP and 1 UA).
Stone composition was different in 21.2% of patients on subsequent analyses.
PMCID: PMC4039594  PMID: 24940457
4.  Royal College surgical objectives of urologic training: A survey of faculty members from Canadian training programs 
According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation.
We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures.
The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesicovaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures.
There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.
PMCID: PMC4081244  PMID: 25024784
5.  Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines: A pilot study 
In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines.
In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1–74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons.
The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05).
This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts.
PMCID: PMC3713157  PMID: 23914275
6.  Clavien classification in urology: Is there concordance among post-graduate trainees and attending urologists? 
We assess the variations between post-graduate trainees (PGTs) and attending urologists in applying the Revised Clavien-Dindo Classification System (RCCS) to urological complications.
Twenty postoperative complications were selected from urology service Quality Assurance meeting minutes spanning 1 year at a tertiary care centre. The cases were from adult and pediatric sites and included minor and major complications. After a briefing session to review the RCCS, the survey was administered to 16 attending urologists and 16 PGTs. Concordance rates between the two groups were calculated for each case and for the whole survey. Inter-rater agreement was calculated by kappa statistics.
There was good overall agreement rate of 81 % (range: 30–100) when both groups were compared. Thirteen of the 20 cases (65%) held an agreement rate above 80% (k = 0.753, p < 0.001) including 3 (15%) cases with 100% agreement. There were only 2 cases where the scores given by PGTs were significantly different from that given by attending urologists (p ≤ 0.03). There was no significant difference between both groups in terms of overall RCCS grades (p = 0.12). When all participants were compared as one group, there was good overall inter-rater agreement rate of 75% (k = 0.71). Although the percent of overall agreement rate among PGTs was higher than the attending urologists (82% [k = 0.79] vs. 69% [k = 0.64]), this was not significantly different (p = 0.68).
There was good overall agreement among PGTs and attending urologists in application of the RCCS in urology. Therefore, it is appropriate for PGTs to complete the Quality Assurance meeting reports.
PMCID: PMC3699078  PMID: 23826044
7.  Simultaneous bilateral subcutaneous pyelovesical bypass as a salvage procedure in refractory retroperitoneal fibrosis 
Ureteral obstruction causing renal failure is the most common complication associated with retroperitoneal fibrosis (RPF). Initial management includes steroid therapy together with ureteral stenting. When these fail, ureterolysis is the recommended surgical procedure. However, this could be challenging and recurrence is common. The aim of the present case series was to assess the feasibility of inserting simultaneous bilateral subcutaneous pyelovesical bypass grafts (SPBGs) in patients presenting with RPF who had failed initial endourologic/surgical management.
PMCID: PMC3699089  PMID: 23826054
8.  Simultaneous bilateral tubeless percutaneous nephrolithotomy: A report of 2 cases and review of the literature 
Percutaneous nephrolithotomy (PCNL) is currently the standard of care to remove large renal calculi. Traditionally, a large-bore nephrostomy tube is placed postoperatively. However, the necessity of this practice has been recently challenged. Theoretically, bilateral tubeless PCNL offers advantages of lower postoperative discomfort, shorter hospital stay and thus lower cost. We review the literature and present two cases of simultaneous bilateral tubeless PCNL from two patients who were referred to a tertiary stone centre from remote areas.
PMCID: PMC3430725  PMID: 23093570
9.  Establishing milestones in urology training: A survey of the Canadian Academy of Urological Surgeons 
At the current time, technical skills are not directly evaluated by the Royal College of Physicians and Surgeons of Canada (RCPSC) as part of the certification process in urology. Rather, the RCPSC relies on the evaluation of Program Directors to ensure that trainees have acquired the necessary surgical skills.
An electronic survey was sent out to the members of the Canadian Academy of Urological Surgeons (CAUS), including the 13 Canadian urology program directors, to assess the teaching and evaluation of technical skills of urology trainees.
The response rate was 37% (33/89), including 8 of the 13 (62%) Program Directors from across Canada. For the teaching of technical skills, most programs had access to live animal laboratories (69%), dedicated teaching time in simulation (59%) and physical training models (59%). Most relied on voluntary faculty. There was a wide variety of structured evaluations for technical skills used across programs, while 36% of respondents did not use structured evaluations. For trainees with deficiencies in technical skills, 67% of programs offered extra operative time with designated faculty, 26% offered additional simulation focused on the deficiency and 19% offered faculty tutorial sessions.
Among Canadian urology residency programs, there is considerable variability in the assessment of technical skills of trainees. Standardized objective assessment tools would help ensure that all trainees have acquired adequate surgical proficiency to operate independently.
PMCID: PMC3367009  PMID: 22664625
10.  Percutaneous Holmium Laser Fulguration of Calyceal Diverticula 
Case Reports in Urology  2012;2012:716786.
Introduction. Calyceal diverticular stones are uncommon findings that represent a challenge in their treatment, due to the technical difficulty in accessing the diverticulum, and the high risk of their recurrence. Current percutaneous technique for calyceal diverticular stones involves establishing a renal access, clearing the stone, and fulguration of the diverticular lining with a roller-ball cautery electrode using hypotonic irrigation solution such as sterile water or glycine solution which may be associated with the absorption of hypotonic fluids with its inherent electrolyte disturbances. Case Report. In this paper, we present for the first time percutaneous holmium laser fulguration of calyceal diverticula in 2 patients using normal saline. Their immediate postoperative sodium was unchanged and their follow-up imaging showed absence of stones. Both patients remain asymptomatic at 30 months post-operatively. Conclusion. This demonstrates that holmium laser is a safe alternative method to fulgurate the calyceal diverticulum after clearing the stone percutaneously.
PMCID: PMC3352233  PMID: 22606636
11.  Variations between two 24-hour urine collections in patients presenting to a tertiary stone clinic 
The current Canadian Urological Association (CUA) guideline recommends two 24-hour urine collections in the metabolic evaluation for patients with urolithiasis. The aim of the present study was to compare two consecutive 24-hour urine collections in patients with a history of urolithiasis presenting to a tertiary stone clinic.
We retrospectively reviewed 188 patients who had two 24-hour collections upon presentation between January 2010 and December 2010. Samples were collected on consecutive days and examined for the following 11 urinary parameters: volume, creatinine, sodium, calcium, uric acid, citrate, oxalate, potassium, phosphorous, magnesium and urea nitrogen. For each parameter, the absolute value of the difference between the two samples rather than the direct difference was compared with zero. Similarly, the percent difference between samples was calculated for each parameter.
The means of the absolute differences between the two samples were significantly different for all 11 urinary parameters (p < 0.0001). The percent differences for all urinary parameters ranged from 20.5% to 34.2%. Furthermore, 17.1% to 47.6% of patients had a change from a value within normal limits to an abnormal value, or vice-versa. Significance was maintained when patients with incomplete or over-collections were excluded.
Significant variations among the two 24-hour urine collections were observed in all of the 11 urinary parameters analyzed. This variation may change clinical decision-making in up to 47.6% of patients if only a single 24-hour urine collection is obtained. The present study supports the CUA guideline of performing two 24-hour urine collections.
PMCID: PMC3289692  PMID: 22396364
12.  Nephrectomy in patients with Caroli’s and ADPKD may be associated with increased morbidity 
Autosomal dominant polycystic kidney disease (ADPKD), characterized by multiple bilateral renal cysts, is the most common inherited disorder of the kidney and an important cause of end-stage renal disease (ESRD). Caroli’s disease is a much less frequent condition with ectasia of the intrahepatic biliary system. A clear association between autosomal recessive and Caroli’s disease has been described, but only 4 cases of ADPKD and Caroli’s disease have been reported with 2 postoperative mortalities. The aim of this case is to increase the awareness of intra-operative and postoperative complications. A 66 year-old male was diagnosed with ADPKD and Caroli’s disease with hepatosplenomegaly and 4 episodes of ascending cholangitis. After 3 years of hemodialysis for ESRD, he received a cadaveric renal allograft. Subsequently, he developed paroxysmal atrial fibrillation. Upon anticoagulation, he developed multiple episodes of gross hematuria from the left native kidney. After the anticoagulation therapy was discontinued, he underwent bilateral nephrectomies of his native kidneys. Intra-operatively, a splenic laceration could not be managed conservatively. Therefore, splenectomy was performed. In addition, he developed ascending cholangitis post-operatively that was treated with antibiotics. He was discharged on postoperative day 18. Genetic testing revealed that the patient is heterozygote for a large deletion in PKD1 gene, which encompasses all tested exons (exons 1–44).
PMCID: PMC3104419  PMID: 21470545
13.  Shock wave lithotripsy in patients requiring anticoagulation or antiplatelet agents 
Extracorporeal shockwave lithotripsy (SWL) remains the only truly minimally invasive procedure for the treatment of upper tract nephrolithiasis. Recently, there has been a recent rise in the patients on antiplatelet agents. Therefore, the aim of the present study is to review the literature available regarding SWL in these high-risk patients requiring anti-coagulation therapy. Alternative therapies to SWL are also presented.
PMCID: PMC3036760  PMID: 21470517

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