David A Tolley

Western General Hospital, Edinburgh, Scotland, United Kingdom

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Publications (176)574.22 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Laparoscopic nephroureterectomy (LNU) offers a superior morbidity profile compared with open nephroureterectomy (ONU) in treating upper urinary tract urothelial cell carcinoma. Evidence of oncological equivalence between LNU and ONU is limited. We compare operative and oncological outcomes for LNU and ONU using matched-pair analysis. Methods: Of 159 patients who underwent a nephroureterectomy at a single institution between April 1992 and April 2010, 13 pairs of ONU and LNU patients were matched for gender, age, tumour location, tumour grade and stage. Operative details, post-operative characteristics and recurrences were collated and survival rates analysed using the Kaplan-Meier method. Results: There was no significant difference in mean operation time between LNU (191 min) and ONU (194 min, p=0.92). There was no significant difference in the 5-year survival rate between LNU and ONU (overall survival 59.1% vs. 73.5%, p=0.18; progression-free survival 24.0% vs. 56.0%, p=0.14; cancer-specific survival 60.9% vs. 73.5%, p=0.56; bladder cancer recurrence-free survival 8.7% vs. 0.0%, p=0.09). Conclusion: Amidst limited RCT and comparative studies, this study presents further evidence of oncological equivalence between LNU and ONU. There was a trend towards poorer outcomes following LNU though, which merits further study.
    Urologia Internationalis 09/2014; 94(2). DOI:10.1159/000364833 · 1.43 Impact Factor
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    ABSTRACT: The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1-T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design. A review of a prospectively collected database at the Western General Hospital, Edinburgh, between 2000 and 2011 was conducted. Patient pairs were matched based on age at operation, gender, histological subgroup, maximal tumour diameter, TNM stage and grade. Patient demographics, operative and post-operative outcomes were compared. Overall, cancer-specific and progression-free survival [overall survival, cancer-specific survival (CSS) and progression-free survival (PFS)] were estimated using the Kaplan-Meier method. From 252 patients with T3 disease, 25 pairs were matched. Patients were of median age 66.2 years, 64 % male. Tumours were all clear cell RCC, were stage pT3a (32 %) or pT3b and had maximal tumour diameters of 8.7 cm for LRN and 10.0 cm for ORN. Estimated blood loss (100 ml LRN; 650 ml ORN, p < 0.001) and length of post-operative hospital stay (4 days LRN: 9 days ORN, p < 0.001) were lower in the LRN group. Operation time and post-operative complication rates were comparable. CSS and PFS were comparable with a mean CSS of 91.3 months for LRN and 88.7 months for ORN. This study reports the longest median follow-up in a T3 LRN cohort. In matched patients, LRN has been shown to have a superior perioperative profile to ORN for the treatment of pT3a/b RCC, with no adverse effect on midterm oncological outcomes.
    World Journal of Urology 03/2014; 33(1). DOI:10.1007/s00345-014-1280-y · 2.67 Impact Factor
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    ABSTRACT: Purpose: To determine the stage-specific operative, postoperative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) in a single center and assess changes over a generation of practice. Patients and methods: From December 1992 to July 2011, data were collected prospectively for 854 consecutive simple laparoscopic necphrectomies (LNs) and LRNs, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage-specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience. Results: There were 206, 71, 118, and 2 patients across stages pT1, pT2, pT3, and pT4, respectively. Median operative time was significantly shorter for pT1 tumors (125, 150 and 150 min for pT1-3, P<0.021), while median estimated blood loss (EBL) was greater for pT3 tumors (50, 50, 100 mL, for pT1-3, P<0.001). Median follow-up time was 31, 30, and 18 months, respectively, across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer-specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts, there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operative time and median EBL in localized disease over the three periods, but no significant changes for locally advanced disease. Conclusion: This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localized RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding, it is also safe in selected T3 disease.
    Journal of endourology / Endourological Society 05/2013; 27(8). DOI:10.1089/end.2012.0562 · 1.71 Impact Factor
  • The Journal of Urology 04/2013; 189(4):e629-e630. DOI:10.1016/j.juro.2013.02.3026 · 4.47 Impact Factor
  • Simon Phipps · Carolann Stephenson · David Tolley
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    ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Shockwave lithotripsy (SWL) can be used to treat stones at any position within the ureter, as long as the stone is radio-opaque and there is a path for the shockwave to reach the stone. However the results of SWL to distal ureteric calculi, with the patient in a prone position, were inferior to those of treating stones within the upper ureter. The transguteal approach allows the lithotripsy shockwave to reach the lower ureter via the greater selatle foramen. This study shows that this approach for SWL to distal ureteric calculi is more effective than the prone approach. OBJECTIVE: To compare the outcomes of extracorporeal shockwave lithotripsy (ESWL) for distal ureteric stones treated using the prone and transgluteal (supine) approaches in a tertiary referral stone unit using a fourth generation lithotriptor. PATIENTS AND METHODS: We selected consecutive patients undergoing ESWL to distal ureteric stones over 1 year, during which we changed our treatment protocol from a prone to transgluteal (supine) approach. Patients were treated using the Sonolith Vision Lithotriptor (Technomed Medical Systems, Vaulx-en-Velin, France). Outcome was assessed using plain abdominal film of kidney, ureter and bladder (KUB) X-ray taken at 2 weeks then monthly as required. Treatment success was defined as complete clearance of stone fragments and treatment failure was defined as persistence of stone fragments beyond 3 months or the need for ureteroscopy. RESULTS: A total of 38 patients were treated in the prone position and 72 patients using a transgluteal approach. Patient and stone characteristics were identical in both groups. The mean (range) stone size was 7.8 (4-16) mm. The proportions of patients who were stone-free after one treatment session within the prone and transgluteal treatment groups were 40 and 78%, respectively (<0.001). The overall success rates for treatment within the prone and transgluteal groups were 63 and 92%, respectively (<0.001). CONCLUSIONS: Transgluteal ESWL to stones within the distal ureter leads to significantly higher stone-free rates than treatment using the prone approach. The majority of patients are rendered stone-free after one session of treatment and the overall success rates are similar to those of ureteroscopic management.
    BJU International 01/2013; 112(2). DOI:10.1111/j.1464-410X.2012.11738.x · 3.53 Impact Factor
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    International Journal of Surgery 12/2012; 10(8). DOI:10.1016/j.ijsu.2012.06.017 · 1.53 Impact Factor
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    ABSTRACT: Purpose: We analyzed the indications for and outcomes of percutaneous nephrolithotomy using upper pole access. Materials and methods: Between 2007 and 2009 prospective data were collected by the Clinical Research Office of the Endourological Society (CROES) from consecutive patients at 96 centers globally. Data on 4,494 patients were included in this analysis. Patients were divided into upper and lower pole access groups based on the location of percutaneous renal access. Preoperative characteristics and outcomes were compared between the 2 groups by univariate and multivariate tests. Results: The upper pole access group had more staghorn stones (21.7% vs 15.5%, p <0.001) and a greater stone burden (mean ± SD 476 ± 390.5 vs 442 ± 344.9 mm(2), p = 0.091). Mean operative time was 92.4 ± 46.1 and 75.1 ± 41.3 minutes in the upper and lower pole groups, respectively (p <0.001). The stone-free rate was lower in the upper pole access group (77.1% vs 81.6%, p = 0.030). The overall complication rate was higher in the upper pole group with a higher incidence of hydrothorax (5.8% vs 1.5%) but a lower incidence of pelvic perforation (1.8% vs 3.2%). Mean hospital stay was longer in the upper pole group (p = 0.048). Success and complication rates were similar in upper pole access subgroups, defined as definitive (staghorn and isolated upper calyceal stones) and elective (pelvic, middle calyceal and lower pole stones) indications. Conclusions: Isolated upper pole access is indicated in a select group of patients with complex stones. Upper calyceal and staghorn stones are more commonly managed by upper pole access, which is associated with a higher complication rate and longer hospital stay as well as a lower stone-free rate due to procedure complexity.
    The Journal of urology 12/2012; 189(2). DOI:10.1016/j.juro.2012.09.035 · 4.47 Impact Factor
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    ABSTRACT: Purpose: We compare the outcomes of endoscopic surgery to laparoscopic nephroureterectomy for the management of specifically noninvasive upper tract urothelial carcinoma. Materials and methods: A retrospective database review identified consecutive patients with clinically noninvasive upper tract urothelial carcinoma who underwent endoscopic surgery (59, via ureteroscopic ablation or percutaneous resection) or laparoscopic nephroureterectomy (70) at a single center during 20 years (1991 to 2011). Overall survival, upper tract urothelial carcinoma specific survival, upper tract recurrence-free survival, intravesical recurrence-free survival, progression-free survival and renal unit survival were estimated using Kaplan-Meier methods, with differences assessed using the log rank test. Results: Median age and followup were 74.8 years and 50 months, respectively. Overall renal preservation in the endoscopic group was high (5-year renal unit survival 82.5%), although this came at a cost of high local recurrence (endoscopic surgery 5-year recurrence-free survival 49.3%, laparoscopic nephroureterectomy 100%, p <0.0001). For G1 upper tract urothelial carcinoma, endoscopic surgery 5-year disease specific survival (100%) was equivalent to that of laparoscopic nephroureterectomy (100%). However, laparoscopic nephroureterectomy demonstrated superior disease specific survival to endoscopic surgery for G2 disease (91.7% vs 62.5%, p = 0.037) and superior progression-free survival for G3 disease (88.9% vs 55.6%, p = 0.033). Conclusions: For G1 upper tract urothelial carcinoma, endoscopic management can provide effective oncologic control and renal preservation. However, endoscopic management should not be considered for higher grade disease except in compelling imperative cases or in patients with poor life expectancy as oncologic outcomes are inferior to those of laparoscopic nephroureterectomy.
    The Journal of urology 12/2012; 189(6). DOI:10.1016/j.juro.2012.12.006 · 4.47 Impact Factor
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    Mark L Cutress · David A Tolley
    European Urology 07/2012; 62(1):181-2. DOI:10.1016/j.eururo.2012.04.012 · 13.94 Impact Factor
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    ABSTRACT: Purpose To compare the characteristics and outcomes of exit strategies following percutaneous nephrolithotomy (PCNL) using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. Materials and methods Two matched data sets were prepared in order to compare stent only versus NT only and TTL versus NT only. Patients were matched on the exit strategy using the following variables: case volume of the center where they underwent PCNL, stone burden, the presence of staghorn stone, size of sheath used at percutaneous access, the presence of bleeding during surgery, and treatment success status. For categorical variables, percentages were calculated and differences between the four groups were tested by the chi-square test. Results The only significant difference reported between the matched pairs was between NT and stent only groups. NT only PCNL was associated with significantly longer operating times (p = 0.029) and longer hospital stay (p < 0.001) than stent only PCNL. Conclusions Patients who undergo PCNL with less invasive exit strategy involving a stent only have shorter hospital stay than those who have postoperative NT. The intraoperative course is the primary driver of complications in PCNL and not necessarily the exit strategy.
    World Journal of Urology 07/2012; 31(5). DOI:10.1007/s00345-012-0898-x · 2.67 Impact Factor
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    ABSTRACT: Introduction Laparoscopic nephrectomy (LN) has largely replaced open nephrectomy. The aim of this study was to describe a validated modular system for training urologists in LN in the context of the shorter training times available in the current era. Methods Following attendance at dry and wet lab courses, three mentees (trainee, new consultant and an experienced open surgeon) were mentored through a five module LN training system in our centre followed by the mentee's own hospital. A minimum of 25 independent procedures were then performed by mentees in their own hospital. Results 17-32 mentored cases were required to become competent in LN, followed by up to 5 observed cases in the mentee's own centre. Subsequently, data from the first 105 cases (80 LN and 25 laparoscopic nephroureterectomies (LNU)) performed by the 3 surgeons after the end of their training without observation by their mentor, were retrospectively collected and analyzed. There were 3 conversions (2.9%). For LN and LNU respectively: median operative time was 140mins (65-390mins) and 180mins (90-300mins); median estimated blood loss 30ml (0-2000ml) and 50ml (0-2000ml); median post-operative stay 4d (2-45d) and 6d (3-27d). Four patients (3.8%) required a post-operative transfusion. There was no 30-day mortality. Conclusion Mentees matched the median British Association for Urological Surgeons (BAUS) registry operating time (LN-120-180mins, LNU-180-240mins) and had lower conversion rates (2.9%vs6.4% for BAUS). Mentees matched median BAUS database reported blood loss (LN and LNU-<500ml) and LOS (LN-4d, LNU-5d). This modular training programme allows urologists to become independent in LN after a short period of focused training in the training centre followed by a short period of mentoring in the mentee's own centre.
    Journal of endourology / Endourological Society 05/2012; 26(11). DOI:10.1089/end.2012.0096 · 1.71 Impact Factor
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    ABSTRACT: Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres.
    BJU International 05/2012; 110(11). DOI:10.1111/j.1464-410X.2012.11169.x · 3.53 Impact Factor
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    ABSTRACT: What's known on the subject? and What does the study add? Endoscopic management of upper tract urothelial carcinoma (UTUC) using either ureteroscopy and laser ablation, or percutaneous resection, is a management option for treating selected low-grade tumours with favourable characteristics. However, the evidence base for such practice is relatively weak, as the reported experience is mainly limited to small case series (level of evidence 4), or non-randomised comparative studies that are unmatched for tumour stage (level of evidence 3b), with variability of follow-up duration and reported outcome measures. The present systematic review comprehensively reviews the outcomes of all studies of endoscopic management of UTUC, including the role of topical adjuvant therapy. It establishes for the first time a structured reference for endoscopic management of UTUC, and is a foundation for further clinical studies.
    BJU International 04/2012; 110(5):614-28. DOI:10.1111/j.1464-410X.2012.11068.x · 3.53 Impact Factor
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    ABSTRACT: Background / Purpose: This study compared the characteristics and outcomes of exit strategies following percutaneous nephrolithotomy (PCNL) using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database. Main conclusion: The exit strategy after PCNL remains a matter of clinical judgment, which should be based on the operative course. The present study shows that tubeless strategies are probably underused despite having been proven to be effective and potentially safer than nephrostomy tube (NT) placement in the small number of cases that were evaluated.
    European Association of Urology Annual Congress 2012; 03/2012
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    ABSTRACT: Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series.
    BJU International 01/2012; 110(6):884-90. DOI:10.1111/j.1464-410X.2011.10850.x · 3.53 Impact Factor
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    ABSTRACT: Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. To review the epidemiology of complications and their prevention and management. A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications. Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports. Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.
    European Urology 01/2012; 61(1):146-58. DOI:10.1016/j.eururo.2011.09.016 · 13.94 Impact Factor
  • British Journal of Medical and Surgical Urology 09/2011; 4(5):220-220. DOI:10.1016/j.bjmsu.2011.06.013
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    ABSTRACT: Open nephroureterectomy (ONU) rather than laparoscopic nephroureterectomy (LNU) is still regarded as the standard of care for extirpative surgical management of upper urinary tract urothelial-cell carcinoma (UUT-UCC). The longest published follow-up of LNU is 7 years. We report outcomes for patients having surgery ≥10 years ago. Consecutive patients with UUT-UCC who were treated with ONU (n=39) or LNU (n=23) between April 1992 to September 2000 were included. Preoperative, tumor, operative and postoperative characteristics, recurrence, and outcomes were collated. Survival was estimated using the Kaplan-Meier method. Median follow-up of censored patients was 163 months (13.6 y). Estimated mean overall survival (OS) was 111 months for ONU and 103 months for LNU. Mean progression free survival (PFS) was 175 months for ONU and 143 months for LNU. Probability of PFS at 10 years was 79% for ONU and 76% for LNU and was unchanged at 15 years. There was no significant difference between ONU and LNU in terms of OS (P=0.51, log-rank test), PFS (P=0.70) or cancer-specific survival (CSS; P=0.43). There were no prognostic differences between ONU and LNU after correcting for confounding variables. There was no increase in the probability of a bladder cancer recurrence from 10 to 15 years postoperation. Long-term follow-up of patients who were operated on more than 10 years ago suggests that LNU has oncologic equivalence to ONU because there were no significant differences in OS, PFS, or CSS between ONU and LNU patients followed for a median of 13 years.
    Journal of endourology / Endourological Society 08/2011; 25(8):1329-35. DOI:10.1089/end.2011.0223 · 1.71 Impact Factor
  • O T Porfyris · M L Cutress · DA Tolley
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    ABSTRACT: Extracorporeal shock wave lithotripsy (SWL) is a non-invasive treatment for urinary tract stones. This review presents the role of SWL for treating specifically ureteric calculi. The impact of hydronephrosis on SWL success, the use of SWL as emergency treatment (eSWL) for acute ureteric colic, the influence of ureteric stent placement on SWL outcome and the use of medical expulsive therapy to augment SWL success are discussed.
    Minerva urologica e nefrologica = The Italian journal of urology and nephrology 06/2011; 63(2):175-82. · 0.97 Impact Factor
  • The Journal of Urology 04/2011; 185(4). DOI:10.1016/j.juro.2011.02.1595 · 4.47 Impact Factor

Publication Stats

3k Citations
574.22 Total Impact Points


  • 1989–2014
    • Western General Hospital
      Edinburgh, Scotland, United Kingdom
  • 2011–2013
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 1987–2013
    • The University of Edinburgh
      • • Edinburgh Urological Cancer Group
      • • Department of Medical Physics and Medical Engineering
      Edinburgh, Scotland, United Kingdom
  • 2006
    • University of Wisconsin–Madison
      Madison, Wisconsin, United States
  • 2004
    • St. Mary Medical Center
      Long Beach, California, United States
  • 1991–1992
    • Bozeman Deaconess Hospital
      Bozeman, Montana, United States
    • Queen Elizabeth Hospital Birmingham
      Birmingham, England, United Kingdom