[S2k guidelines on diagnostics, therapy and metaphylaxis of urolithiasis (AWMF 043/025) : Compendium]

[Renal colic]

INTRODUCTION

Renal colic accounts for 5-10% of all emergency department visits, making it a common condition in acute medicine. The typical clinical presentation is an early indication of urolithiasis.

DIAGNOSIS

Diagnostic measures include laboratory tests, ultrasound, and low-dose noncontrast computed tomography (CT) scans. Kidney, ureter, bladder (KUB) plain film radiography has been widely replaced by low-dose noncontrast CT with similar radiation dosage. In special patient groups such as children or pregnant women, ionizing radiation should be avoided if possible.

TREATMENT

General measures involve pain management (non-steroidal anti-inflammatory agents, opioids) and empirical antibiotic treatment for suspected bacterial infection. Depending on the location/size of the stone, pharmacological stone expulsion therapy may be considered. In cases of obstructive pyelonephritis or acute renal insufficiency, early urinary drainage (JJ stent/nephrostomy) is recommended. Definitive stone removal may be performed primarily in some cases (rather small and rather distal ureterolithiasis). It is common to schedule stone removal as a secondary intervention.

Flank free modified supine versus prone ultra mini percutaneous nephrolithotomy in treatment of medium sized renal pelvic stone a randomized clinical trial

INTRODUCTION & OBJECTIVES

percutaneous nephrolithotomy (PNL) is the standard treatment of renal stone more than 2 cm. ultra-mini-percutaneous nephrolithotomy had emerged in the last decade as a new technique in treating renal stones less than 2 cm. in this study we compare between outcomes of (UMP) in modified flank free supine (FFSP), and prone position.

MATERIALS & METHODS

A prospective randomized study was conducted between January 2016 and April 2020, including 122 patients, divided into two matched groups. Group A included 61 patients who underwent UMP in FFSP, and group B included 61 patients who underwent UMP in a prone position. All patients had a single renal pelvic stone 1-2 cm. Patients with a single kidney, renal anomalies, BMI≥40, history of ipsilateral renal surgery, and age less than 18 years were excluded. In both groups, the dilatation was done up to 13 f; a holmium laser was used through a 9f ureteroscope for fragmentation. Nephrostomy tube and ureteric stent were used only when indicated.

RESULTS

122 patients who divided into two groups. The mean age was 40.09±13.63 and 39.67±13.80 years in both groups, respectively. The operative time was 63.64±9.22 and 78.48±9.55 minutes in groups A &B, respectively (P=0.0001). The fluoroscopy time was 3.47±0.56 and 4.45±0.39 minutes in groups A &B, respectively (P=0.0001).no significant difference between both groups regarding operative and post-operative complications. Shift to miniPNL was needed in one patient in group A and four patients in group B due to impaired vision. The hospital stay was 25.36±4.23 and 26.13±4.76 hours in both groups, respectively. The initial stone-free rate was 95.1% and 91.8% in both groups, respectively.

CONCLUSIONS

ultra-mini-percutaneous nephrolithotomy in modified supine position shows comparable results to the prone position regarding stone-free rate, hospital stay, and perioperative complication, with significantly shorter operative and fluoroscopy time.

[Interrater reliability and clinical impact of the Post-Ureteroscopic Lesion Scale (PULS) grading system for ureteral lesions after ureteroscopy : Results of the German prospective multicenter BUSTER project]

BACKGROUND

The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort.

MATERIALS AND METHODS

Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3).

RESULTS

Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p < 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p < 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0.

CONCLUSIONS

Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.

["We're going to place a ureteral stent …" : Development and use of the terms stent and splint by German-speaking urologists]

The use of eponyms has a long history in medicine. But it is a rare case that a term not associated with a procedure or an anatomical description has come into use. The terms "stent" and "splint" in German and English used as a verb and a noun are a typical example. The coronary stent was named after Charles Thomas Stent (1807-1885). Charles Theodore Dotter (1920-1985) was the one who introduced the eponym into the literature of angiography in 1983. The change in urology occurred after an article of Willard Goodwin especially in the English literature but did not come into constant use in the German language.

Surgical management of urolithiasis - a systematic analysis of available guidelines

Background

Several societies around the world issue guidelines incorporating the latest evidence. However, even the most commonly cited guidelines of the European Association of Urology (EAU) and the American Urological Association (AUA) leave the clinician with several treatment options and differ on specific points. We aimed to identify discrepancies and areas of consensus between guidelines to give novel insights into areas where low consensus between the guideline panels exists, and therefore where more evidence might increase consensus.

Methods

The webpages of the 61 members of the Societé Internationale d’Urologie were analysed to identify all listed or linked guidelines. Decision trees for the surgical management of urolithiasis were derived, and a comparative analysis was performed to determine consensus and discrepancies.

Results

Five national and one international guideline (EAU) on surgical stone treatment were available for analysis. While 7 national urological societies refer to the AUA guidelines and 11 to the EAU guidelines, 43 neither publish their own guidelines nor refer to others. Comparative analysis revealed a high degree of consensus for most renal and ureteral stone scenarios. Nevertheless, we also identified a variety of discrepancies between the different guidelines, the largest being the approach to the treatment of proximal ureteral calculi and larger renal calculi.

Conclusions

Six guidelines with recommendations for the surgical treatment of urolithiasis to support urologists in decision-making were available for inclusion in our analysis. While there is a high grade of consensus for most stone scenarios, we also detected some discrepancies between different guidelines. These are, however, controversial situations where adequate evidence to assist with decision-making has yet to be elicited by further research.

A Novel Decision Aid to Support Informed Decision-Making Process in Patients with a Symptomatic Nonlower Pole Renal Stone <20 mm in Diameter

INTRODUCTION

Stone disease is an important health problem, and patients have different treatment choices. Shared decision making is recommended for deciding the treatment type, but patient education is necessary. Decision aids (DAs) are used for this aim, and herein, we developed a novel DA for patients with symptomatic nonlower pole renal stones <20 mm in diameter.

MATERIALS AND METHODS

The DA development process was established based on the recommended guides. General characteristics of the stone disease and details of the shockwave lithotripsy and retrograde intrarenal surgery were included in the content of the DA. The DA was further revised based on the suggestions of different physician groups and patients. The DA was evaluated by three physicians (Delphi assessment-International Patient Decision Aid Standards [IPDAS] Collaboration standards) and 25 patients (questionnaire of six questions with five-point Likert scale).

RESULTS

The DA was designed as a booklet, and Delphi group assessment resulted in a total score of 50/54. Patient evaluation of the DA resulted in favorable outcomes, and patients generally recommended its use by other patients.

CONCLUSIONS

This novel DA for patients with a symptomatic nonlower pole renal stone <20 mm showed promising results and was well accepted by the patients. We believe that this DA will have a positive impact on patients' level of knowledge. Increased level of knowledge will also improve the patients' contribution to the shared decision-making process. A further prospective randomized trial to compare with the standard patient informing process is also planned.

[Extracorporeal shock wave lithotripsy]

Interventional treatment of stones essentially consists of three treatment modalities. Extracorporeal shockwave lithotripsy (ESWL), in addition to uterorenoscopy (URS) and percutaneous nephrolitholapaxy (PCNL) is an essential treatment pillar and is the only noninvasive therapy option for the treatment of urinary stones. After a long period of ESWL being the leading choice in stone treatment, the number of SWL interventions diminished in recent years in favor of the other two treatment modalities (URS and PCNL). This article describes the indications, surgical technique and management of complications of SWL.

[What is the current status of shock wave lithotripsy?]

BACKGROUND

Shock wave lithotripsy (SWL) became the therapy of choice for the majority of patients with urolithiasis early after its introduction in the early 1980s. Since then, SWL remains the only noninvasive therapy modality for the treatment of urinary stones. Although lithotripters became more versatile and affordable-making them available worldwide-indications for SWL have shifted as well. In most western countries, endoscopic techniques took the lead in stone therapy due to high (early) stone-free and better reimbursement rates. Notwithstanding SWL remains the first-line therapy for most intrarenal and many ureteral stones.

PURPOSE

This contemporary review illuminates technical aspects and improvements of lithotripsy over recent years in context with the current guideline recommendations.

RESULTS

Technical advances in lithotripsy such as shock wave generation, focusing, coupling, stone localization and modifications in therapy regimens are reviewed and presented.

CONCLUSIONS

Urologists are recommended to carefully select the appropriate therapy modality for a patient with urolithiasis. A more comprehensive understanding of the physics of shock waves could lead to much better results, thus, endorsing SWL as first-line therapy for urolithiasis instead of contemporary endourology treatment options.

[Urolithiasis 2016 : Reliable, effective and low radiation exposure]

BACKGROUND

Urolithiasis is a widespread disease. Diagnostic imaging plays an important role in the evaluation and management of patients with suspected urolithiasis. Furthermore, modern imaging methods may provide information on stone location, size, fragility and composition aiding the urologist to determine the appropriate treatment modality.

PURPOSE

Based on the current literature and guidelines, this review reports on the various new and established diagnostic imaging modalities.

RESULTS

Ultrasound should always be the initial imaging modality. Following ultrasound, noncontrast CT-principally using a low-dose protocol-is the imaging modality of choice in the evaluation of patients with acute flank pain and suspected urolithiasis. New imaging modalities like dual energy CT, Uro Dyna CT and digital tomosynthesis are currently under investigation but not yet part of daily clinical practice. Magnetic resonance imaging can be used to detect obstruction caused by urinary stones but is not a first-line imaging modality.

[Ureterorenoscopy]

Ureterorenoscopy (URS) is a minimally invasive treatment option for removal of kidney stones, which has gained importance in this field over the past two decades. This technique has replaced extracorporeal shock wave lithotripsy (ESWL) stone surgery for many indications. It is also particularly important in the diagnostics and treatment for tumors of the upper urinary tract. This article describes the indications, surgical technique and management of complications of URS.

Miniaturization of percutaneous nephrolithotomy Smaller, but better?

PURPOSE OF REVIEW

Miniaturized percutaneous nephrolithotomy (PCNL) procedures have reached big popularity in the past years. Following the idea that decreasing the diameter of the instruments would decrease the complication rate instruments with outer diameter down to 4,8 Fr was established. In this review, we want to take a critical insight of the most popular miniaturized procedures, regarding the key advantages and disadvantages of the miniaturized instruments.

RECENT FINDINGS

For all techniques displayed, a number of studies are available to support their effectivity in the given range of indication. Naturally, the body of evidence for M-sized instruments is largest, as it exists in the armamentarium since long, whereas studies comparing small or extrasmall and extraextrasmall to standard or among each other are rare. However, large studies comparing miniaturized procedures with conventional PCNL in randomized controlled fashion are still lacking, too.

SUMMARY

Miniaturization and attending developments such as ultrasonographic-guided puncture, single step dilatation of the tract, low irrigation pressure in open systems and a tubeless procedure lead to lower complication rates in PCNL. All of the established procedures have their own range of indication with regard to size and location of the stone. They amplified the possibility of a customized therapy for each patient.

[Urolithiasis guidelines: retrospective view and perspectives]

The first German guidelines on urolithiasis were published in four sections in "Der Urologe A" in 1997 and were listed at The Association of the Scientific Medical Societies in Germany (AWMF) in 1999. The European Association of Urology (EAU) published the first guidelines on urolithiasis in 2000. All guidelines must be updated on a regular basis. Guidelines should represent the highest level of evidence for the best diagnostic and therapeutic procedures, independent of economic pressure. Guidelines should safeguard optimal patient care and also serve as a basis for education and training of healthcare professionals. They are a tool for quality management and for national healthcare structures and strategies as well as for the judicature. Medical guidelines form the foundation for the elaboration of local clinical treatment pathways, which are the bridge to treatment of patients and also take economic and regional circumstances into consideration. In the future information technology (IT) could play an even more important role for both the complex methods of establishing guidelines and their implementation. The contents of guidelines could then be directly integrated into the clinical pathway, if necessary or into electronic patient charts in order to propose a medically and financially optimized treatment pathway. Because of the complexity of producing guidelines, they will in part be produced at a national level and adapted to the regional circumstances. Future technical, medical and genetic developments will lead to a multidisciplinary and multiprofessional cooperation in the production of guidelines.

[Individualized evidence-based interventional stone treatment : One stone, many question marks?]

The treatment of urolithiasis is still one of the most frequent tasks in the daily urological practice. Driven by the technological developments, patient demands and also personal experiences of urologists, many interventional treatment options have been established. To identify the most suitable treatment option, it is of utmost importance to consider not only stone size and localization but also the individual situation of the patient and the published evidence, which despite all efforts often lags behind the technical and clinical reality.