Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Urolithiasis is a major clinical and economic burden for health care systems. International epidemiological data suggest that the incidence and prevalence of stone disease is increasing. This study demonstrates that the number of diagnoses and procedures relating to kidney stone disease has increased significantly in the last 10 years in the UK. Management of stone disease comprises a significant and increasing proportion of urological practice in the UK, which has implications for work force planning, training, service delivery and research in this field. OBJECTIVE To summarize the changes in prevalence and treatment of upper urinary tract stone disease in the UK over the last 10 years. METHODS Data from the Hospital Episode Statistics (HES) website (http://www.hesonline.nhs.uk) were extracted, summarized and presented. RESULTS The number of upper urinary tract stone hospital episodes increased by 63% to 83 050 in the 10‐year period. The use of shock wave lithotripsy (SWL) for treating all upper tract stones increased from 14 491 cases in 2000–2001 to 22 402 cases in 2010 (a 55% increase) with a 69% increase in lithotripsy for renal stones. There was a 127% increase in the number of ureteroscopic stone treatments from 6 283 to 14 242 cases over the 10‐year period with a 49% increase from 2007/2008 to 2009/2010. There was a decline in open surgery for upper tract stones from 278 cases in 2000/2001 to 47 cases in 2009/2010 (an 83% reduction). Treatment for stone disease has increased substantially in comparison with other urological activity. In 2009/2010, SWL was performed almost as frequently as transurethral resection of the prostate or transurethral resection of bladder tumour, ureteroscopy for stones was performed more frequently than nephrectomy, radical prostatectomy and cystectomy combined, and percutaneous nephrolithotomy was performed more frequently than cystectomy. CONCLUSIONS The present study highlights the increase in prevalence and treatment of stone disease in the UK over the last 10 years. If this trend continues it has important implications for workforce planning, training, service delivery and research in the field of urolithiasis.

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This trial demonstrates that percutaneous nephrolithotomy without nephrostomy or stent is a safe and well tolerated procedure in selected patients. Length of stay was reduced with no major complications in either group. We believe that totally tubeless percutaneous nephrolithotomy may be considered an accepted standard of care for selected cases and it is possible to reserve placement of a nephrostomy tube or internal ureteral stent for specific indications.

This study demonstrates that PCNL without nephrostomy or stent is a safe and well-tolerated procedure in selected patients. It is the authors' belief that totally tubeless PCNL may be considered an accepted standard of care for selected patients, and it is possible to reserve placement of a nephrostomy tube or internal ureteral stent for specific indications.

What's known on the subject? and What does the study add?• Percutaneous treatment for renal stone disease is associated with a risk of significant morbidity.• Our large UK series provides contemporary data on the risk of vascular complications and admission to the Intensive Care Unit (ICU) after PCNL. When compared with recent international databases, these data support the current evidence that better outcomes can be achieved in centres performing large numbers of procedures. These data add to the debate for the centralisation of specialist stone surgery. Objective• To audit the outcome of percutaneous nephrolithotomy (PCNL) at a UK stone centre over a 10-year period, and provide patients with understandable contemporary data on blood loss and vascular risk. Patients and Methods• A single centre retrospective analysis of all PCNLs undertaken between April 2000 and December 2010.• The association between transfusion and patient age, operative duration and positive preoperative mid-stream urine (MSU) sample was subject to statistical analysis. Results• Data on 568 patients was analysed. 21 were paediatric cases with a mean (range) age of 8 (2-16) years; 547 were adult cases with a mean (range) age of 55 (17-84) years. • 3.8% of adult patients (21/547) received a blood transfusion; mean age 60 years (55 years in those not transfused) with a mean operative duration of 119 min (103 min in those not transfused).• 23.8% of patients transfused had a confirmed preoperative urinary tract infection compared with 16.1% of those not transfused.• Seven patients underwent angiography, with five having selective arterial embolisation (0.9%).• There were no deaths in this series although one patient (0.2%) required an urgent nephrectomy due to cardiovascular instability from bleeding. Conclusions• Large UK series that provides contemporary data for consent on vascular risk at PCNL. • The risk of transfusion is associated with increased patient age, operative duration and the presence of a positive preoperative MSU sample.• Data compares favourably with other large published series, and supports the argument for centralisation of percutaneous stone management.

Approximately 10% of Caucasian men will expect to suffer from renal stone disease by the age of 70 years. It is a growing problem in the UK, with a cross-sectional prevalence of approximately 1.2%. These statistics mean there are approximately 720,000 individuals with a history of kidney stones in the UK. 1 The increased prevalence of kidney stones parallels the well-publicised increase in the nation's prevalence of obesity and its well-documented relationship to urolithiasis. 2In 1912, the first visualisation of the upper urinary tract was performed by Hampton Young. He achieved this by passing a cystoscope into a mega-ureter of a paediatric patient. Subsequent developments in optics have revolutionised endourology and established the ureteroscopic treatment of ureteric and renal calculi.Although a comparison between extracorporeal shockwave lithotripsy (ESWL) and ureterorenoscopy (URS) removal of stones from the lower calyx of the kidney has failed to show a significantly better result with URS, 3 the updated 2007 American Urological Association/European Association of Urology (AUA/EAU) guidelines, and recent Cochrane meta-analysis, suggest that stone-free rates are superior with URS for all stone sizes and for all positions in the ureter, apart from stones in the upper third less than 10 mm in size. 4 Standard access to the ureter for endoscopic management of stone disease may be difficult due to anatomic abnormalities, a narrow ureteric lumen, tortuous ureteric path or previous instrumentation (Fig. 1). Failure of access will usually lead to the placement of a ureteric stent. The alternative for these difficult, tight ureters is extensive balloon dilatation, with the risk of trauma and the potential for long-term stricture formation. Difficulty may be encountered with retrograde access for rigid and flexible ureterorenoscopy (URS) due to anatomic abnormalities, a narrow ureteric lumen, tortuous ureteric path or previous instrumentation. Ureteric dilatation using a balloon or tapered dilator can occasionally fail and will usually lead to the placement of a ureteric stent. We present our experience and incidence of pre-stenting after failed standard access and dilatation techniques, the aim being to quote a figure for the patient at the time of consent. PATIENTS AND METHODS Data were collected prospectively from a single surgeon at a regional tertiary referral stone unit. The outcomes of those patients pre-stented, for failed access, were recorded. RESULTS Between December 2007 and December 2008, a total of 119 patients underwent flexible and rigid URS. Mean patient age was 49 years (range, 19-86 years). Of these, 107 cases were undertaken for urolithiasis and 12 cases for diagnosis of upper tract malignancy. 12% (13/107) of cases were for pain and non-diagnostic imaging and 8.4% (9/107) of patients were pre-stented because of failed access, without complication, and subsequently had successful interval treatment. Of the remaining successful cases of confirmed urolithiasis, 33% (28/85) and 67% (56/85) were und...

Objective To evaluate the effect of contact laser prostate surgery in the treatment of benign prostatic hyperplasia. Patients and methods A prospective double-blind randomized controlled trial of transurethral resection of the prostate (TURP) and contact laser prostatectomy was conducted, with an economic evaluation of both procedures. The primary outcome measure was the change in the American Urologic Association symptom score, with secondary outcome measures being the peak urinary¯ow rate, treatment-related complications, re-operation rate and health service costs. Results The perioperative blood loss and transfusion requirements were statistically signi®cantly lower for laser prostatectomy than for TURP. There was no clinically signi®cant difference between TURP and contact laser prostatectomy in the mean change in symptom scores and¯ow rates. There were distinct perioperative advantages in favour of the contact laser treatment, but some disadvantages in terms of recatheterization and re-operation rates. Conclusions Contact laser prostatectomy is a valid treatment for benign prostatic hypertrophy. The performance of contact laser prostatectomy as daycase surgery would have cost advantages to the National Health Service.