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.

Background:

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.

Methods:

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.

Results:

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.

Conclusion:

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.

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.

Introduction:

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.

Methods:

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.

Results:

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.

Conclusions:

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.

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).

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.