BJU International (2002), 90(Suppl. 1), 1–72 Tuesday 25 June 10.30–11.45 Stones Chairmen: N. Burgess and A. Joyce 016 flexible ureterorenoscopy and electrohydraulic or holmium laser fragmentation. Two patients had primary open procedures, one had Should the acute management of flank pain in the UK be stent insertion and removal, and one underwent percutaneous changed? nephrolithotomy (PCNL); one patient was treated conservatively. Conclusion Morbid obesity presents many problems for the uro- R.L. Davies, S.M. Mason, R.A. Nakielney*, K.J. Hastie* and logical surgeon. The introduction of flexible ureteroscopy provides D.J. Rosario* Northern General Hospital and *Royal an extremely useful first-line treatment of upper tract stone disease, Hallamshire Hospital, Sheffield as ESWL is not possible. The success of flexible ureteroscopy avoids the need for PCNL or open surgery where appropriate, and con- Introduction The management of acute flank pain suggestive of sequent complications associated with surgery in the obese, but urolithiasis is traditionally based on clinical assessment, urine expertise in all forms of stone surgery is required in this difficult analysis and standard radiography. Unenhanced spiral CT allows a patient group. rapid, noninvasive, accurate assessment of this condition, and can be undertaken in the accident and emergency department (A&E), but availability is limited. The aim of this study was to assess the 018 accuracy of the current approach to acute flank pain with a view to evaluating the potential benefits of definitive imaging in A&E. Percutaneous nephrolithotomy in the morbidly obese Patients and methods Emergency cards and hospital notes of patient patients admitted from A&E to urology between 1 April 2000 and 31 March 2001 were reviewed. Of 577 admissions, 331 (57%) were G.J. Burtt, B.J. Koo, A. Haq and N.A. Burgess Norfolk and for suspected urolithiasis. Complete data were available in 258 Norwich University Hospital, UK (78%). Univariate and multivariate analyses were used to identify possible predictors of urolithiasis, including age, gender, dipstick Introduction The surgical management of morbidly obese patients 2 haematuria results, duration of pain and requirement for opiate (body mass index, BMI, >40 kg/m ) with renal calculi presents analgesia. unique challenges because of the increased operative and anaes- Results In all, 145 (56%) patients had confirmed urological pathol- thetic morbidity in this group. ogy after investigation by a combination of urography, ultra- Patients and methods We reviewed the records of eight morbidly sonography and spiral CT (93 with urolithiasis, 45 UTI and seven obese patients and 16 consecutive patients with a BMI of <40 and other); 24 (9%) had significant nonurological diagnoses requiring undergoing percutaneous nephrolithotomy (PCNL) in our unit intervention including abdominal aortic aneurysm (three), appen- between November 1999 and April 2001. In the obese group the 2 dicitis (two), pneumonia (three) and gynaecological disease (nine). mean weight was 137.8 kg, with a mean BMI of 44.7 kg/m . In the Eighty-nine (35%) were discharged with no diagnosis after the normal group the mean weight was 75.4 kg and the mean BMI 2 symptoms resolved. The sensitivity and specificity for urolithiasis of 25.7 kg/m . The operative duration, length of hospital stay, change male gender, age <50 years, dipstick haematuria, pain duration in haemoglobin concentration and incidence of complications was <12 h and opiate analgesia were 78% and 39%, 77% and 35%, compared between the groups. 100% and 11%, 68% and 68% and 47% and 25%, respectively. Results For the obese and normal patients the respective mean Conclusion Clinical criteria cannot reliably be used to predict (range) operative duration was 74 (50–97) and 74 (37–150) min, urolithiasis nor exclude significant non-urological disease, leading the mean postoperative haemoglobin change was x13 g/L and to inappropriate urological admissions in 44% of these patients. x14 g/L and the median hospital stay 5 and 4 days. In the obese These data make a compelling case for definitive imaging of acute group access was not achieved in one patient because of scarring flank pain in A&E. from a previous PCNL. Of the obese patients, 85% were stone-free after surgery, compared with 94% of the normal patients. Complication rates were low in both groups. 017 Conclusion PCNL is feasible in the morbidly obese, with results that are comparable to those in normal patients. Morbidly obese patients Stone disease in the morbidly obese should not be denied percutaneous renal surgery. M.F. Bultitude, B. Challacombe, R.C. Tiptaft and J.M. Glass Guy’s and St Thomas’ Hospital, London 019 2 2 Introduction The body mass index (BMI, weight/[height] , kg/m ) Holmium:YAG lasertripsy for ureteric calculi – is that is an objective measure of obesity. Morbid obesity is defined as a stent really necessary? BMI of >40. Obesity presents several challenges in the treatment of urolithiasis, as in other surgical procedures. Specific difficulties in M.S. Simms, M. Ashraf, R.J. Lemberger and M.C. Taylor patients with urinary tract calculi include problems with imaging Kings Mill Centre for Health Care Services, Mansfield, UK and treatment. Poor image quality with both X-ray and ultrasono- graphy can result in a reliance on CT and plain films. ESWL is Introduction Routine JJ stenting after holmium:YAG lasertripsy for contraindicated in patients too heavy for the operating table. ureteric calculi has been advocated by some institutions, although Difficulties in positioning the patient and an increased skin-to-stone stents are associated with local discomfort and irritative LUTS. In depth can make percutaneous access challenging, resulting in early our department we have avoided stenting wherever possible after recourse to ureteroscopic intervention. We present our experience in stone fragmentation and we present our experience. 11 morbidly obese patients with stone disease treated in our unit Patients and methods The notes and X-rays of patients undergoing over a period of 18 months. ureteroscopy for ureteric calculi between 1995 and 2001 were Patients and methods The mean (range) weight of the patients was reviewed. A 7.5 F Wolff rigid ureteroscope was used in all 144 (127–160) kg, with a mean BMI of 45. Six patients underwent procedures and stones destroyed using a 20 W holmium:YAG # 2002 BJU International 1 2 BAUS 2002 laser through a 365-mm fibre. Outcome measures included stone- Patients and methods We retrospectively reviewed the notes of free rates, number of repeat procedures and complications. all patients undergoing PCNL at our institution, over the previous Results In all, 118 procedures were conducted in 107 patients 5 years. The patients included three with transplanted kidneys and (mean age 49.1 years); 102 patients were not stented and 16 had three with horseshoe kidneys. The size of stone and requirement stents inserted after stone fragmentation. In the unstented group, for fragmentation, number of patients rendered stone-free, post- follow-up was available in 98. There were 39 proximal, 13 mid and operative complications and length of hospital stay were analysed. 46 distal ureteric calculi. Stone-free rates were 74%, 77% and 93%, Results In all, 187 PCNLs were performed by two surgeons, of which respectively, and the number of patients who required repeat 54 (29%) did not have a PNT. In the tubeless group the mean procedures in each group was six, none and one. In this group (interquartile range) stone size was 16 (12–20) mm, compared with overall there was one ureteric stricture. In the 16 patients who were 19 (15–21) mm in the PNT group. These differences were not stented there were eight proximal, six mid and two distal ureteric significant (P>0.05). In patients without PNT, 39 (72%) were calculi; six, three and two patients were rendered stone-free, rendered stone-free after a single PCNL, compared with 60% of respectively. There were two strictures overall in this group. patients with PNT. The mean (interquartile range) size of the Conclusion It is clear that routine stenting is unnecessary after residual fragments was 8 mm in both the tubeless group (4–12 mm) holmium lasertripsy for ureteric calculi. and the group with PNT (5–13 mm) (P>0.05). Blood transfusion was required in three (5%) of the tubeless group and four (3%) in the PNT group. No patients developed sepsis or required subsequent 020 placement of a nephrostomy tube for sepsis or obstruction. The mean hospital stay was 3 (2–3) days in the tubeless group and Laparoscopic ureterolithotomy: technical considerations 4.8 (3–6) days in the PNT group (P=0.01). and long-term follow-up Conclusion The initial size of the stone, or of the residual fragments, did not appear to significantly influence the decision to place a D.D. Gaur, S. Trivedi, M.R. Prabhudesai and M. Gopichand PNT. The tubeless PCNL is a safe technique for the uncomplicated Bombay Hospital Institute of Medical Sciences, Bombay, India stone. It allows patients to be discharged home earlier and does not Introduction Although laparoscopic ureterolithotomy has been increase the incidence of postoperative sepsis or other complications. reported in various studies the technical details and long-term complications have not been analysed. We report our 10-year experience of retroperitoneal laparoscopic ureterolithotomy. 022 Patients and methods Laparoscopic ureterolithotomy was under- taken in 108 patients between 1991 and 2001, all except one using Supracostal approach for percutaneous nephrolithotomy: the retroperitoneal approach. The mean (range) stone size was a review of causes of pulmonary complications 16 (10–47) mm, and they were located in the upper ureter in 79, M.G. Andankar, P.N. Maheshwari†, M. Bansal† and mid ureter in 13 and lower ureter in 16 patients. Twelve patients had more than one stone, with the maximum being six in a S.