Current status of ureteroscopy for stone disease in pregnancy. Urolithiasis. 2014;42:1-7. [PMID: 24374899 DOI: 10.1007/s00240-013-0635-y]

Ureterorenoscopy for stone disease in pregnancy: a literature review and update

PURPOSE OF REVIEW

Management of stone disease in pregnancy poses a challenge for all healthcare professionals involved in their care. During pregnancy, there is an increase in the incidence of urolithiasis. Major technological and procedural advances have been seen in the last decade for endoscopic management of urolithiasis. The purpose of this review is to provide a comprehensive workup of available literature on use of ureteroscopy for stone treatment during pregnancy.

RECENT FINDINGS

We identified 268 articles on screening, of which 28 were included in the final review. Overall adverse event rates were low, with no severe complications reported in the included studies. On multivariate analysis, the only significant correlation was an inverse relationship between calculated caseload and adverse obstetric events. No further correlation could be found between caseload, operation technique and adverse event rates. Data quality was low among the included studies.

SUMMARY

While ureteroscopy is a relatively safe and effective option for active stone treatment during pregnancy, they should be performed in experienced endourology centres in conjunction with obstetric teams.

Urological Guidelines for Kidney Stones: Overview and Comprehensive Update

BACKGROUND

Evidence-based guidelines are published by urological organisations for various conditions, including urolithiasis. In this paper, we provide guidance on the management of kidney stone disease (KSD) and compare the American Urological Association (AUA) and European Association of Urologists (EAU) guidelines.

METHODS

We evaluate and appraise the evidence and grade of recommendation provided by the AUA and EAU guidelines on urolithiasis (both surgical and medical management).

RESULTS

Both the AUA and EAU guidelines provide guidance on the type of imaging, treatment options, and medical therapies and advice on specific patient groups, such as in paediatrics and pregnancy. While the guidelines are generally aligned and based on evidence, some subtle differences exist in the recommendations, but both are generally unanimous for the majority of the principles of management.

CONCLUSIONS

We recommend that the guidelines should undergo regular updates based on recently published material, and while these guidelines provide a framework, treatment plans should still be personalised, respecting patient preferences, surgical expertise, and various other individual factors, to offer the best outcome for kidney stone patients.

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.

Has the COVID-19 pandemic affected ureteral stone management in pregnant women? A retrospective single-center study

INTRODUCTION

This study aimed to evaluate the effect of coronavirus disease (COVID-19) on the patients' referral in the pregnant population and also investigate each treatment approach's advantages and disadvantages for acute renal colic in pregnancy.

METHODS

In this retrospective study, we included all pregnant women with ureteral stones referred to a referral center between January 2019 and March 2021.

RESULTS

Among 53 pregnant women, 18 (33.9%) were on conservative therapy, which passed the stone without any complications. Double J stent or nephrostomy tube insertion was done for 24 patients (45.2%). Seventeen of these patients (70.8%) presented post-surgical complications, including hematuria (29.2%), pyelonephritis (20.8%), and lower urinary tract symptoms (20.8%). Transurethral lithotripsy (TUL) was done in 11 patients (20.7%). Only one of these patients developed hematuria following TUL. Thus, in our population study, double J stent or nephrostomy insertion was associated with a higher chance of postoperative complications than TUL (p-value = 0.001). Thirty-six patients were referred within 13 months before the entry of COVID-19, while 17 were referred during a similar approximate duration after the COVID-19 entry into the country. Only the initial presentation had a significant difference between these two periods (p-value = 0.034).

CONCLUSIONS

When conservative treatment fails, we recommend TUL as the second-line treatment over temporary procedures, such as double J stent or nephrostomy insertion. Of note, in a group of patients with an emergent clinical setting, including active infection, deteriorating renal function, signs of preterm labor, solitary kidney, etc., double J or nephrostomy tube insertion remains the preferred management method for its fast resolution of obstruction and infection. Besides, a decrease in visits with an increase in complicated cases after COVID-19 was observed, maybe due to a delay in referring.

Ureteroscopy during pregnancy: Outcomes and lessons learned over 4 decades at a tertiary center in Norway

Background

The management of suspected kidney stone disease in pregnancy is challenging. In cases of persistent flank pain and where investigations may have rendered equivocal results, ureteroscopy (URS) is a recognized diagnostic and therapeutic intervention. This study aimed to investigate the safety and outcomes associated with performing URS during pregnancy, as the technique has evolved over the past 4 decades at our center.

Materials and Methods

We performed a retrospective analysis of pregnant patients who underwent URS at our tertiary center between 1984 and 2022. Outcomes of interest included anesthetic approach, operative time, hospital stay, and complications.

Results

Eighty-seven pregnant patients underwent 96 URS procedures, and 60% (n = 57) of these procedures were performed during the third trimester. Overall, 58% (n = 56) of the procedures were achieved with local anesthesia and light sedation. During the most recent decade, the latter was successfully carried out in 97% of the procedures, with the remainder occurring under spinal anesthesia as per patient choice. Overall, 57% (n = 50) of the whole study group had ureteral calculi found at the time of surgery and in 88% (n = 44) of these cases, fragmentation/extraction was performed. The remainder had insertion of ureteral stent with definitive clearance deferred until postpartum. Mean operative time and postprocedure hospital stay was 33 minutes (range, 7-100 minutes) and 2.2 days (range, 0-16 days), respectively. The overall intraoperative and postoperative complication rates were 2% and 11%, respectively. During the final decade, the latter improved to 6% and all adverse events were minor (Clavien I/II), with the exception of a single case. Regarding exit strategy, ureteral stent was placed in 42% (n = 40) of the procedures, 23% (n = 22) had ureteral catheter inserted, and the remainder (35%, n = 34) had none.

Conclusions

Ureteroscopy can be safely performed during pregnancy using anesthetic approach with local anesthesia and light sedation. Development of a local protocol and multidisciplinary management algorithm are instrumental in enabling the delivery of such a service.

ALARA in Urology: Steps to Minimise Radiation Exposure During All Parts of the Endourological Journey

Purpose of the Review

The global burden of kidney stone disease (KSD) and its management relies on ionising radiation. This includes the diagnosis, treatment and follow-up of KSD patients. The concept ‘As Low As Reasonably Achievable’ (ALARA) developed in response to the radiation risks and the key principles include optimisation, justification and limitation of radiation. This article provides an overview of the topic including background to the risks and steps that can be taken during all stages of endourological management.

Recent Findings

Our review suggests that ionising radiation is an invaluable tool in delineating the anatomy, localising disease, guiding manoeuvres and monitoring treatment in patients with KSD. It therefore plays an integral role in many stages of patient care; preoperatively, intraoperatively and postoperatively.

The reduction of radiation pre- and post-surgical intervention relies on the use of low-radiation CT scan and ultrasound scan. It can also be achieved through various intraoperative techniques or fluoroless techniques in selected patients/procedures, customised to the patients and procedural complexity.

Summary

There are many parts of the patient journey where exposure to radiation can take place. Urologists must be diligent to minimise and mitigate this wherever possible as they too face exposure risks. Implementation of strategies such as teaching programmes, fluoroscopy checklists and judicious use of CT imaging among other things is a step towards improving practice in this area.

Management of Kidney Stone Disease in Pregnancy: A Practical and Evidence-Based Approach

PURPOSE OF REVIEW

Suspected kidney stone disease during pregnancy is a difficult condition for health professionals to manage. This is partly due to the more limited range of diagnostic and therapeutic strategies, which can be safely applied. A comprehensive review of literature was performed to identify evidence to develop a practical guide to aid clinicians.

RECENT FINDINGS

Ultrasound remains the recommended first line option for imaging. Complicated cases, such as suspected infected obstructed system, require urgent decompression such as in the form of percutaneous nephrostomy. This article highlights the pharmacotherapeutic agents, which are considered safe for use in pregnancy. Where surgical intervention is indicated, evidence supports ureteroscopy to be a safe option as long as infection has been treated. Ureteroscopy can offer definitive clearance of the stone(s) and can be less burdensome regarding bothersome symptoms compared to indwelling ureteral stent or nephrostomy, which also require regular exchange due to the high propensity for encrustation in pregnancy. A multidisciplinary approach is fundamental to safely manage suspected kidney stone disease in pregnancy. Adoption of a locally agreed pathway as suggested in this article supports improved patient care.

Role and importance of ergonomics in retrograde intrarenal surgery (RIRS): outcomes of a narrative review

BACKGROUND

With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy (fURS) to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments, and outline future directions and recommendations in order to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists.

METHODS

This study was carried out according to the PRISMA guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy (URS), retrograde intrarenal surgery (RIRS), laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data was consolidated for analysis.

RESULTS

A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analysed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS.

CONCLUSION

Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.

Safety and feasibility of percutaneous nephrolithotomy (PCNL) during pregnancy: A review of literature

OBJECTIVE

Management of nephrolithiasis during pregnancy can be challenging because of the potential risks to the mother and fetus. Diagnosis and treatment can be a dilemma owing to the anatomical and physiological changes, besides the limitation in the use of X-rays. The aim of this article was to identify any case series or case reports where percutaneous nephrolithotomy (PCNL) was used as a treatment modality for nephrolithiasis in pregnancy.

MATERIAL AND METHODS

A review of the literature was performed using Medline, EMBASE, CINAHL, and Scopus from 1990 to October 2019. A search was conducted using the following search terms: "urolithiasis," "renal stones," "stone disease," "kidney stones," "pregnancy," "pregnant," "percutaneous nephrolithotomy," "PNL," and "PCNL." The initial search strategy retrieved 52 articles, but after going through them, only 7 were suitable for inclusion in this review.

RESULTS

Overall, seven studies reported regarding 16 patients who underwent PCNL procedure during pregnancy. The patients were aged 18-34 years and had the procedure between 11 and 32 weeks of gestation. Most stones were in the renal pelvis or pelvic-ureteric junction and sized 8-40 mm, with the most common indication for the intervention being refractory pain. Most treatments used ultrasound guidance, and X-ray fluoroscopy was employed only in two cases. No complications occurred to the mother or fetus in any of the case reports, suggesting that PCNL is a safe and feasible treatment for patients with persistent symptoms when conservative treatment has failed.

CONCLUSION

All the reported cases of PCNL achieved stone-free status with no complications. Although PCNL has been evidenced to be safe, it must be performed by experienced endourologists after careful consultation with the obstetricians. Patient counseling and multidisciplinary team decision-making are paramount in such complex scenarios.

Worldwide survey of flexible ureteroscopy practice: a survey from European Association of Urology sections of young academic urologists and uro-technology groups

Introduction

To understand the current practice of flexible ureteroscopy (fURS), we conducted a worldwide survey among urologists with a special interest in endourology.

Material and methods

A 42-question survey was designed after an initial consultation with European Association of Urology young academic urologists (YAU) and uro-technology (ESUT) groups. This was distributed via the SurveyMonkey^® platform and an ESUT meeting to cover practice patterns and techniques in regard to ureteroscopy usage worldwide.

Results

A total of 114 completed responses were obtained. A safety guidewire was reportedly used by 84.5% of endourologists, an access sheath was always or almost always used by 71% and a reusable laser fibre was used by two-thirds of respondents. While a combination of dusting and fragmentation was used by 47% as a preferred mode of intra-renal stone treatment, some used dusting (43%) or fragmentation with basketing (10%).

Disposable scopes were only used by 40% and three quarters of them used it for challenging cases only. Antibiotic prophylaxis was limited to a single peri-operative dose by two-thirds (67%) of respondents. The procedural time was limited to between 1–2 hours by two-thirds (70%) of respondents and very rarely (7.4%) it exceeded 2 hours. The irrigation method varied between manual pump (46%), mechanical irrigation (22%) or gravity irrigation (27%).

Conclusions

Our survey shows a wide variation in the available endourological armamentarium and surgical practice amongst urologists. However, there seems to be a broad agreement in the use of peri-operative antibiotics, access sheath usage, method of stone treatment and the use of post-operative stent.

Characteristics of current digital single-use flexible ureteroscopes versus their reusable counterparts: an in-vitro comparative analysis

Background

Single-use flexible ureterorenoscopes (fURSs) have been recently introduced aiming to offer solutions to the sterilization, fragility and cost issues of the reusable fURSs. In order to be a viable alternative, the single-use scopes must prove similar capabilities when compared to their reusable counterparts. The goal of our in-vitro study was to compare the current reusable and single-use digital fURSs regarding their deflection, irrigation and vision characteristics.

Methods

We compared in-vitro 4 single-use fURSs-LithoVue™ (Boston Scientific, Marlborough, Massachusetts, USA), Uscope™ (Zhuhai Pusen Medical Technology Co. Ltd., Zhuhai, Guangdong Province, China), NeoFlex™ (NeoScope Inc, San Jose, California, USA) and ShaoGang™ (YouCare Technology Co. Ltd., Wuhan, China) versus 4 reusable fURSs-FLEX-X^c (Karl Storz SE & Co KG, Tuttlingen, Germany), URF-V2 (Olympus, Shinjuku, Tokyo, Japan), COBRA vision and BOA vision (Richard Wolf GmbH, Knittlingen, Germany). Deflection and irrigation abilities were evaluated with different instruments inserted through the working channel: laser fibres (200/273/365 µm), retrieval baskets (1.5/1.9/2.2 Fr), guide wires [polytetrafluoroethylene (PTFE) 0.038 inch, nitinol 0.035 inch] and a biopsy forceps. A scoring system was designed to compare the deflection impairment. Saline at different heights (40/80 cm) was used for irrigation. The flow was measured with the tip of the fURS initially straight and then fully deflected. The vision characteristics were evaluated (field of view, depth of field, image resolution, distortion and colour representation) using specific target models.

Results

Overall, the single-use fURSs had superior in-vitro deflection abilities than the reusable fURSs, in most settings. The highest score was achieved by NeoFlex™ and the lowest by ShaoGang™. PTFE guide wire had most impact on deflection for all fURSs. The 200 µm laser fibre had the lowest impact on deflection for the single-use fURSs. The 1.5 Fr basket caused the least deflection impairment on reusable fURSs. At the end of the tests, deflection loss was noted in most of the single-use fURSs, while none of the reusable fURSs presented deflection impairment. ShaoGang™ had the highest irrigation flow. Increasing the size of the instruments occupying the working channel led to decrease of irrigation flow in all fURSs. The impact of maximal deflection on irrigation flow was very low for all fURSs. When instruments were occupying the working channel, the single-use fURSs had slightly better in-vitro irrigation flow than the reusable fURSs. The field of view was comparable for all fURSs, with LithoVue™ showing a slight advantage. Depth of field and colour reproducibility were almost similar for all fURSs. ShaoGang™ and Uscope™ had the lowest resolution. FLEX X^c had the highest image distortion while LithoVue™ had the lowest. Partial field of view impairment was not for Uscope™ and ShaoGang™.

Conclusions

In-vitro, there are differences in technical characteristics of fURSs. It appears that single-use fURSs deflect better than their reusable counterparts. Irrespective of deflection, the irrigation flow of the single-use fURSs was slightly superior to the flow of the reusable fURSs. Overall, reusable fURSs had better vision characteristics than single-use fURSs. Further in-vivo studies might be necessary to confirm these findings.

Reusable flexible ureterorenoscopes are more cost-effective than single-use scopes: results of a systematic review from PETRA Uro-group

Clinical data suggest an equipoise between single-use (disposable) and reusable flexible ureterorenoscope (fURS) in terms of scope characteristics, manipulation, view and clinical outcomes. The procedural cost of reusable fURS is dependent on the initial and repair cost, maintenance and scope sterilization and on the number of procedures performed/repair. We conducted a systematic review on the procedural cost ($) of fURS based on the individual authors reported data on the number of procedures performed before repair and to see if it is a feasible option compared to single use fURS. A systematic review carried out in a Cochrane style and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist using Medline, Scopus, CINAHL, EMBASE and Cochrane library for all English language articles. All papers on fURS cost analysis were searched from 2000-2018 (19 years), which mentioned the cost of fURS based on the number of procedures performed and the repairs needed (procedure/repair) as reported by the individual authors. Six studies reported on both the number of procedures performed with number of repairs needed and the cost calculated/procedure in the given time period. The number of uses/repair in various studies varied between 8-29 procedures and the cost per procedure varied between $120-1,212/procedure. A significant trend was observed between the decreasing cost of repair with the number of usages. With studies reporting on a minimum of 20 cases/repair the mean cost was around $200/procedure. This is contrast to the disposable scopes such as Lithovue ($1,500-2,000/usage) and Pusen ($700/usage). The cost of reusable fURS is low in centres performing a high volume of procedures. Similarly, when a reasonable volume of procedures is performed before scope repair, the cost is lower than the disposable scopes. Although, the disposable and reusable scopes seem to be comparable in terms of their performance, this review proves that reusable fURS are still more cost effective than disposable scopes.

Outcomes of ureteroscopy for stone disease in anomalous kidneys: a systematic review

Introduction

Treatment of stone disease in anomalous kidneys can be challenging. As ureteroscopy (URS) has advanced, the number of studies reporting on outcomes of URS for stone disease in anomalous kidneys has increased. Our objective was to perform a systematic review of the literature to evaluate the outcomes of URS for stone disease in this group of patients.

Methods

A Cochrane style review was performed in accordance with the PRISMA guidelines using Medline, EMBASE, CINAHL, Cochrane Library, Scopus and individual urologic journals for all English language articles between inception and June 2018.

Results

Fourteen papers (413 patients) with a mean age of 43 years and a male to female ratio of 285:128 were included. The underlying renal anomaly was horseshoe kidney (n = 204), ectopic kidney (n = 117), malrotation (n = 86), cross fused ectopia (n = 2) and others (n = 2). With a mean stone size of 16 mm (range 2–35 mm), the majority of stones were in the lower pole (n = 143, 34.6%) or renal pelvis (n = 128, 31.0%), with 18.9% (n = 78) having stones in multiple locations. Treatment modality included the use of flexible ureteroscope in 90% of patients and ureteral access sheath used in 11 studies. With a mean operative time of 61.3 min (range 14–185 min), the initial and final SFR was 76.6% (n = 322) and 82.3% (n = 340), respectively. The overall complication rate was 17.2% (n = 71), of which 14.8% were Clavien I/II and the remaining 2.4% were Clavien ≥ III complications.

Conclusion

Although ureteroscopy in patients with anomalous kidneys can be technically challenging, advancements in endourological techniques have made it a safe and effective procedure. In these patients the stone-free rates are good with a low risk of major complications.

'Negative Ureteroscopy' for Stone Disease: Evidence from a Systematic Review

PURPOSE OF REVIEW

While ureteroscopy (URS) is a common procedure for ureteric stones, this window between diagnosis and treatment leaves the possibility for a 'negative', 'stoneless' or 'diagnostic' URS. We perform a systematic review to look at the rate of 'negative ureteroscopy' and risk factors associated with it.

RECENT FINDINGS

From a total of 3599 articles and 68 abstracts, 4 studies (1336 patients) were selected. The negative URS rate varied from 4 to 14%. Common predictors seem to be female gender, small stones, radiolucent stones and distal ureteric stones. Although infrequent, negative ureteroscopy should be avoided in patients with ureteric stones by performing a low-dose CT scan on the day of surgery. This should especially be performed for females and those with smaller, radiolucent or distal ureteric stones.

Outcomes and Long-Term Follow-Up with the Use of Ureteral Access Sheath for Pediatric Ureteroscopy and Stone Treatment: Results from a Tertiary Endourology Center

PURPOSE

The aim of this study was to retrospectively analyze outcomes of flexible ureteroscopy and laser fragmentation (FURSL) of renal stones with the use of ureteral access sheath (UAS) in the pediatric population.

MATERIALS AND METHODS

We retrospectively collected data between January 2011 and January 2018 for patient demographics, stone characteristics, and outcomes in 21 children who underwent FURSL with the use of UAS.

RESULTS

Twenty-one patients (10 boys and 11 girls) with a mean age of 11.8 years (range: 2-16 years) underwent FURSL using an access sheath. The stone location was in the lower pole in 13 patients (62%) with 12 patients (57%) having multiple stones. A 9.5F (35 cm) Cook Flexor UAS was used in all cases. The mean and overall stone size was 12 mm (range: 5-30 mm) and 15.4 mm (range: 5-35 mm), respectively. Preoperative stent was present in 8(38%) patients, and a postoperative stent or overnight ureteric catheter was inserted in 14 patients (67%). Thirty-one procedures (average: 1.5/patient) were needed to achieve a stone-free rate of 95%. There were no procedural or long-term complications noted over a mean follow-up of 26 months (4-37 months).

CONCLUSION

The use of UAS in the treatment of pediatric renal stones is safe and feasible with good outcomes and without any long-term sequelae.

Ureteroscopy and stone treatment in the elderly (≥70 years): prospective outcomes over 5- years with a review of literature

Objective:

To assess outcomes of ureteroscopy for treatment of stone disease in the elderly. Ureteroscopy (URS) is an increasingly popular treatment modality for urolithiasis and its applications are ever expanding with the development of newer technologies. Its feasibility and outcomes within the elderly population to our knowledge remain under-reported.

Materials and Methods:

We examined the patient demographics and surgical outcomes from our prospective database for patients ≥70 years who underwent URS for urolithiasis, in a 5-year period between March 2012 and December 2016.

Results:

A total of 110 consecutive patients underwent 121 procedures (1.1 procedure/patient) with a mean age of 77.2 years (range: 70-91 years). Stone location was in the kidney/ pelviureteric junction (PUJ) in 29%, ureter in 37% and in multiple locations in 34%. The initial and final stone free rate (SFR) was 88% and 97% respectively. While 73% were done as true day case procedures, 89% patients were discharged within 24 hours. Eleven patients (9%) underwent complications of which 10 were Clavien I/II including acute urinary retention, urinary tract infection, stent symptoms and pneumonia. One patient underwent Clavien IV complication where they needed intensive care unit admission for urosepsis but fully recovered and were discharged home subsequently.

Conclusion:

Ureteroscopy is a safe and effective method of managing urolithiasis in elderly patients. Although most patients are discharged within 24-hours, consideration needs to be made for patients where social circumstances can impact their discharge planning.

The Role of Social Media and Internet Search Engines in Information Provision and Dissemination to Patients with Kidney Stone Disease: A Systematic Review from European Association of Urologists Young Academic Urologists

INTRODUCTION

Kidney stone disease (KSD) affects millions of people worldwide and has an increasing incidence. Social media (SoMe) and search engines are both gaining in usage, while also being used by patients to research their conditions and aid in managing them. With this in mind, many authors have expressed the belief that SoMe and search engines can be used by patients and healthcare professionals to improve treatment compliance and help counseling and management of conditions such as KSD. We wanted to determine whether SoMe and search engines play a role in the management and/or prevention of KSD.

MATERIALS AND METHODS

The databases MEDLINE, Embase, CINAHL, Scopus, and Cochrane Library were used to search for relevant English language literature from inception to December 2017. Results were screened by title, abstract, and then full text, according to the inclusion and exclusion criteria. The data were then analyzed independently by the authors not involved in the original study.

RESULTS

After initial identification of 2137 records and screening of 42 articles, 10 studies met the inclusion and exclusion criteria. The articles included focused on a variety of SoMe forms, including two articles each on twitter, YouTube, smartphone apps, and Google search engine and one article on Google insights and Google analytics. Regarding patient centered advice, while two articles covered advice on dietary, fluid intake, and management options, two additional articles each covered advice on fluid advice and management options only, while no such advice was given by three of the SoMe published articles.

CONCLUSIONS

SoMe and search engines provide valuable information to patients with KSD. However, while the information provided regarding dietary aspects and fluid management was good, it was not comprehensive enough to include advice on other aspects of KSD prevention.

The comparation of effects and security of double-J stent retention and ureteroscopy lithotripsy in the treatment of symptomatic ureteral calculi during pregnancy

OBJECTIVE

To describe the efficacy of double-J stent retention and ureteroscopy lithotripsy, we performed a study to evaluate the management of symptomatic ureteral calculi during pregnancy.

MATERIALS AND METHODS

From January 2005 and June 2015, 53 pregnant women with symptomatic ureteral calculi were admitted and treated in our hospital. According to the treatment techniques, there were divided into two groups: double-J stent retention group (30 cases) and ureteroscopy lithotripsy group (23 cases). We collected the characteristics and treatment outcome of the patients.

RESULTS

Double-J stent retention was performed on 30 patients. And the stents were successfully inserted in 25 patients (83.3%). 4 cases got complication in double-J group (16%). The mean operating time, medical cost and hospitalization time of double-J group were 20.6 min, 1632 yuan and 1.3 days. Ureteroscopy lithotripsy was performed on 23 patients. 20 patients were operated successfully (87.0%). 2 cases got complication in ureteroscopy group (10.0%). The mean operating time, medical cost and hospitalization time of ureteroscopy group were 41.5 min, 2792 yuan and 6.0 days.

CONCLUSION

In summary, both double-J stent retention and ureteroscopy lithotripsy are effective and safe in the managation of ureteral calculi during pregnancy.

Advances in Lasers for the Treatment of Stones-a Systematic Review

PURPOSE OF REVIEW

Laser lithotripsy is increasingly used worldwide and is a continuously evolving field with new and extensive research being published every year.

RECENT FINDINGS

Variable pulse length Ho:YAG lithotripters allow new lithotripsy parameters to be manipulated, and there is an effort to integrate new technologies into lithotripters. Pulsed thulium lasers seem to be a viable alternative to holmium lasers. The performance of similar laser fibers varies from manufacturer to manufacturer. Special laser fibers and "cleaving only" fiber tip preparation can be beneficial for the lithotripsy procedure. Different laser settings and the surgical technique employed can have significant impact on the success of laser lithotripsy. When safely done, complications of laser lithotripsy are rare and concern the endoscopic nature of procedure, not the technology itself, making laser lithotripsy one of the safest tools in urology. Laser lithotripsy has had several new developments and more insight has been gained in recent years with many more advances expected in the future.

Safety and Efficacy of Day-case Percutaneous Nephrolithotomy: A Systematic Review from European Society of Uro-technology

CONTEXT

Day case or ambulatory percutaneous nephrolithotomy (PCNL) has risen over the last few years with the aim of discharging patients within 24h.

OBJECTIVE

We perform a systematic review of literature to evaluate the outcomes of day-case PCNL surgery.

EVIDENCE ACQUISITION

A Cochrane style search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Web of Science. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. All studies in the English language reporting on PCNL patients discharged within 24h were included.

EVIDENCE SYNTHESIS

Based on the literature search of 97 articles, nine (502 patients) met the inclusion criteria (mean age: 47 yr), with a mean stone size of 20.5mm. The mean operating time was 66min, and over a mean hospital stay of 17.5h, the stone-free rate was 95%. The overall complication rate was 13.5%; the vast majority of these complications were Clavien I-II complications, with a readmission rate of 3%.

CONCLUSIONS

Day-case PCNL is a safe and feasible strategy in carefully selected cases. However, for its success, detailed planning and adherence to surgical protocol are paramount with strict criteria for inpatient admission and a thorough follow-up plan.

PATIENT SUMMARY

Day-case percutaneous nephrolithotomy procedure seems to be a safe procedure with good outcomes, and low risk of complications and readmissions. Detailed preoperative protocol and planning are paramount, with indications for inpatient admission as well as a thorough follow-up plan.

Semi-rigid ureteroscopy: indications, tips, and tricks

Advances in ureteroscopic technology, alongside broadening treatment options have fuelled the rapid expansion of endourology. Semi-rigid ureteroscopy is a well-known procedure used globally for varying urological conditions, with high success rates. This article aims to provide ‘tips and tricks’ for the semi-rigid ureteroscopy procedure, and the management of commonly encountered pathology such as renal stones, ureteric strictures, and urothelial tumours.

Review on diagnosis and management of urolithiasis in pregnancy: an ESUT practical guide for urologists

PURPOSE

Management of urolithiasis in pregnancy can be challenging for most urologists with diagnostic and treatment dilemma to ensure the best outcome for both mother and fetus. We wanted to review the literature for urolithiasis in pregnancy with a practical management guide for urologists.

METHODS

A non-systematic review of literature was carried out for all English language literature using Medline. To ensure a more comprehensive search, the review of diagnosis and management of pregnant patients with urolithiasis was carried out separately, by two authors independently. Due to diagnostic complexity, investigations (US, CT, MRI) carried out were assessed separately.

RESULTS

Our search included diagnostic studies such as US, CT and MRI (73, 20 and 27 articles, respectively) and management studies (55 articles in total). Details on etiology, radiation risk, safety of various diagnostic modalities, medications and treatment options are covered through an evidence-based approach. We provide a practical guide for urologists in what is clearly a stressful situation for patient and physician alike.

CONCLUSIONS

Urolithiasis in pregnancy needs a careful multidisciplinary management to achieve good outcomes for both mother and baby. Our review shows that a balanced approach for diagnosis and treatment seems to achieve the best outcomes in pregnancy.

Ureteroscopy for stone disease: expanding roles in the modern era

INTRODUCTION

The prevalence of urolithiasis is increasing worldwide and is causing significant morbidity and cost to the healthcare systems. While ureteroscopy (URS) has been established as a treatment option, our review highlights the expanding role of URS for the management of more complex stones and patients in the modern era.

MATERIAL AND METHODS

Ureteroscopy has shown to have good outcomes with stone free rates (SFR) comparable to other treatment modalities. Relevant publications have been identified. Their findings were critically appraised and used to formulate clinically oriented conclusions.

RESULTS

The use of URS has increased and now includes URS management for large stones, bilateral stone disease, obesity, pregnancy, pediatrics, solitary kidney, horseshoe kidney and patients with a bleeding diathesis.

CONCLUSIONS

With advances in URS technique and technology, its role has expanded to offer treatment in difficult clinical scenarios with good outcomes.

Bilateral Simultaneous Ureteroscopic (BS-URS) Approach in the Management of Bilateral Urolithiasis Is a Safe and Effective Strategy in the Contemporary Era-Evidence from a Systematic Review

PURPOSE OF REVIEW

Ureteroscopic treatment of urolithiasis has become safer and more effective in the modern era. With a rise in the incidence of bilateral urolithiasis, management dilemma of staged single-side ureteroscopy versus bilateral simultaneous ureteroscopy (BS-URS) is often debatable. This review evaluates the current evidence base for bilateral simultaneous ureteroscopic approach in the modern era.

RECENT FINDINGS

A systematic review was conducted from 1990 to June 2016 including all English language articles reporting on outcomes of BS-URS for urolithiasis. Data was split into two periods: period 1: 2003-2012 and period 2: 2013-2016, and analysed using SPSS version 21. A total of 11 studies (491 patients) were identified from a literature search of 148 studies with mean age of 45 years and a male: female ratio of 2:1 and a mean operative time of 69 min (SD = ±15). The initial and final stone-free rate (SFR) was 87 and 93%, respectively. Post-operative stents were placed in 89% of patients with a mean hospital stay of 1.6 days (SD = ±0.5). Overall, there was a significant negative association between case volume (procedures per month) and complication rate (p = 0.045). Mean hospital stay was significantly longer in period 1 (1.9 days, SD = ±0.5) than period 2 (1.3 days, SD = ±0.3) and complications were also significantly higher in period 1 (47%) compared to period 2 (12%) (p < 0.001). There were six studies examining holmium laser (HL) lithotripsy and three examining pneumatic lithotripsy (PL). There were significantly more complications after PL than HL; however, their SFR was similar. Our review shows that the complication rates and hospital stay are significantly reduced in the contemporary data suggesting an improving trend in outcomes following BS-URS. Simultaneous bilateral ureteroscopic treatment of urolithiasis is safe and effective in the modern era. Safety is increased in centers with increased number of procedures performed and with laser lithotripsy.

Renal colic during pregnancy: Diagnostic and therapeutic aspects. Literature review

Introduction

Renal colic during pregnancy is a rare urgency but is one of the most common non-obstetric reasons for hospital admission. The management often means a challenge for the urologist and gynecologist due to the complexity involved in preserving the maternal and fetal well-being.

Material and methods

We performed a literature search within the PubMed database. We found 65 related articles in English. We selected 36 for this review prioritizing publications in the last two decades.

Results

The anatomical and functional changes of the genitourinary system during pregnancy are well documented; also during pregnancy, there are several metabolic pro-lithogenic factors. The most common clinical presentation is flank pain accompanied by micro or macro hematuria. US provides data identifying renal obstruction shown by an increased renal resistance index. MRI allows differentiating the physiological dilatation from the pathological caused by an obstructive stone showing peripheral renal edema and renal enlargement. Low dose CT has been determined to be a safe and highly accurate imaging technique. Once the diagnosis is confirmed, the initial management of patients should be conservative. When conservative management fails the interventional treatment is mandatory, a urinary diversion of the obstructed renal unit either by a JJ stent or through a PCN catheter has to be done. The definitive management of the stone can be done in the postpartum or deferred ureteroscopy can be considered during pregnancy.

Conclusions

Renal colic during pregnancy is an uncommon urgency, so it is important for the urologist to know the management of this condition.

Optimal management of lower pole stones: the direction of future travel

INTRODUCTION

Kidney stone disease is increasing worldwide with its most common location being in the lower pole. A clear strategy for effective management of these stones is essential in the light of ever increasing choice, effectiveness, and complications of different treatment options.

MATERIAL AND METHODS

This review identifies the latest and clinically relevant publications focused on optimal management of lower pole stones.

RESULTS

We present an up-to-date European Association of Urology and American Urological Association algorithm for lower pole stones, risks and benefits of different treatments, and changing landscape with the miniaturization of percutaneous stone treatments.

CONCLUSIONS

Available literature seems to be deficient on quality of life, patient centered decision making, and cost analysis of optimal management with no defined standard of 'stone free rate', all of which are critical in any surgical consultation and outcome analysis.

Safety and feasibility of day case ureteroscopy and laser lithotripsy (URSL) in patients with a solitary kidney

Introduction

The management of nephrolithiasis in patients with a solitary kidney poses a treatment challenge. The study aimed to evaluate the outcomes of ureteroscopy and laser stone fragmentation (URSL) for renal stones in these patients treated in our university teaching hospital.

Material and methods

Between July 2012 and December 2014, seventeen cases of URSL for stones in a solitary kidney were reviewed. Patient demographics, stone dimensions, perioperative and post-operative outcomes were recorded in a prospectively maintained database. Serum creatinine levels pre-procedure and at follow-up were also compared.

Results

Seventeen cases of URSL were conducted with a mean age of 52.9 ±19.9 years. 8 of the 17 (47%) patients had stones in multiple locations and 13 (76%) were in the lower pole. The mean ± SD stone size and BMI were 13.0 ±8.9 mm and 31.6 ±5.8 kg/m², respectively. The stone free rate (SFR) was 82.5%. Fourteen (82.5%) patients were discharged the same day and 16 cases (94%) were discharged within 24 hours. For patients with deranged pre-operative serum creatinine, the mean serum creatinine level improved from 131.2 ±68.3 µmol/L pre-URSL to 106.5 ±36.7 µmol/L at follow-up. There was one Clavien grade II complication with a patient requiring additional antibiotics for post-operative urinary tract infection. There were no other major or minor complications.

Conclusions

Day case ureteroscopy for stone disease in a solitary kidney is safe and feasible with a low complication rate and an overall improvement in renal function.

Application of Ureteroscope in Emergency Treatment with Persistent Renal Colic Patients during Pregnancy

Background

Although the application of ureteroscopy in the treatment of ureteral calculi during pregnancy has been on the rise, for persistent renal colic patients without ultrasound-detected ureteral calculi, it may represent a clinical dilemma due to the potential risks for both mother and fetus.

Objective

The aim of the present study is to present our experience with the application of the ureteroscope in the emergency treatment of persistent renal colic patients during pregnancy.

Methods

From March 2009 to September 2014, a total of 117 pregnant women who received ureteroscopy for persistent renal colic were retrospectively analyzed. Patients were divided into three groups according to duration of the persistent renal colic: Group A (within 12 hours; 24 cases); Group B (12 to 24 hours; 76 cases); and Group C (more than 24 hours; 17 cases). The stone-free rate, complications, and other qualitative data were analyzed.

Results

Of the 117 patients, 31 patients who were found not to have renal or ureteral calculi received ureteroscopic double-J (DJ) stent insertion, whereas 86 patients who were found with ureteral calculi received ureteroscopic lithotripsy (URSL) and DJ stent insertion. Among them, 24 patients (27.9%) were found with ureteral calculi by ureteroscopy rather than ultrasound. In addition, 73 patients (84.9%) had complete fragmentation of calculi; 12 patients (10.3%) had a threatened abortion (the rates of threatened abortion in Groups A, B and C were 8.3% vs. 6.5% vs. 29.4%; Group C compared with Groups A and B, p<0.05), and one patient (1.2%) had urosepsis (in Group C). However, these complications were cured with conservative treatment, without postpartum infant and maternal complications.

Conclusion

For pregnant patients with persistent renal colic/ureteral calculi and hydronephrosis, ureteroscopic DJ stent insertion and URSL are effective and safe options when conservative treatment fails, even if no urinary calculi were found by ultrasound. At the same time, for patients with persistent renal colic during pregnancy, early application of ureteroscopy may reduce the risk of preterm birth.

Urolithiasis in pregnancy: a cost-effectiveness analysis of ureteroscopic management vs ureteral stenting

OBJECTIVE

The purpose of this study was to determine the cost-effectiveness of serial stenting vs ureteroscopy for treatment of urolithiasis during pregnancy as a function of gestational age (GA) at diagnosis.

STUDY DESIGN

We built decision analytic models for a hypothetical cohort of pregnant women who had received a diagnosis of symptomatic ureteral calculi and compared serial stenting to ureteroscopy. We assumed ureteral stent replacement every 4 weeks during pregnancy, intravenous sedation for stent placement, and spinal anesthetic for ureteroscopy. Outcomes were derived from the literature and included stent infection, migration, spontaneous kidney stone passage, ureteral injury, failed ureteroscopy, postoperative urinary tract infection, sepsis, and anesthetic complications. Four separate analyses were run based on the GA at diagnosis of urolithiasis. Using direct costs and quality-adjusted life years, we reported the incremental costs and effectiveness of each strategy based on GA at kidney stone diagnosis and calculated the net monetary benefit. We performed 1-way and Monte-Carlo sensitivity analyses to assess the strength of the model.

RESULTS

Ureteroscopy was less costly and more effective for urolithiasis, irrespective of GA at diagnosis. The incremental cost of ureteroscopy increased from -$74,469 to -$7631, and the incremental effectiveness decreased from 0.49 to 0.05 quality-adjusted life years for a kidney stone diagnosed at 12 and 36 weeks of gestation, respectively. The net monetary benefit of ureteroscopy progressively decreased for kidney stones that were diagnosed later in pregnancy. The model was robust to all variables.

CONCLUSION

Ureteroscopy is less costly and more effective relative to serial stenting for urolithiasis, regardless of the GA at diagnosis. Ureteroscopy is most beneficial for women who received the diagnosis early during pregnancy.

Flexible ureteroscopy: Technological advancements, current indications and outcomes in the treatment of urolithiasis

The last 3 decades have witnessed great improvements in the technology and clinical applications of many minimally invasive procedures in the urological field. Flexible ureteroscopy (fURS) has advanced considerably to become a widely utilized diagnostic and therapeutic tool for multiple upper urinary tract pathologies. The most common indication for fURS is the treatment of upper urinary tract stones with the aid of Holmium:Yttrium Aluminium Garnet (YAG) laser lithotripsy. Advancements in endoscope technologies and operative techniques have lead to a broader application of fURS in the management of urolithiasis to include larger and more complex stones. fURS has proved to be an effective and safe procedure with few contraindications. Continued progression in fURS may increase its clinical applicability and supplant other procedures as the first line treatment option for urolithiasis.

Ureteroscopy and stones: Current status and future expectations

Urolithaisis is becoming an ever increasing urological, nephrological and primary care problem. With a lifetime prevalence approaching 10% and increasing morbidity due to stone disease, the role of ureteroscopy and stone removal is becoming more important. We discuss the current status of stone disease and review the ever increasing role that ureteroscopy has to play in its management. We discuss technological advances that have been made in stone management and give you an overview of when, how and why ureteroscopy is the most common treatment option for stone management. We touch on the role of robotic ureteroscopy and the future of ureteroscopy in the next 10 years.

Pushing the boundaries of ureteroscopy: current status and future perspectives

Substantial advances in ureteroscopy have resulted in the incorporation of this procedure into routine urological practice in many centres worldwide. Subsequently, an abundance of clinical data and technological progression have enabled the development of novel solutions that have increased the efficacy of ureteroscopy, and reduced associated morbidity and costs. In addition the indications for this retrograde approach have been expanded, and pyelocalyceal diverticulum, infundibular stenosis, urolithiasis in pregnant women or in patients with urinary diversions, as well as upper urinary tract tumours can now be managed using this methodology. New endoscopes are continuously developed, with different manufacturers choosing various technical solutions to further increase the efficacy and safety-and sometimes decrease costs-of ureteroscopy, including miniaturization, inclusion of digital optical systems and dual working channels, and the introduction of disposable apparatus. The holmium laser, currently the most-versatile energy source available, enables tissue incision, tumour ablation, and intracorporeal lithotripsy. Modern ancillary instruments are diverse, flexible, and durable, and novel devices used in daily clinical practice can minimize ascendant migration of stone fragments and, therefore, decrease the failure rate of the retrograde ureteroscopic approach. However, the peak of ureteroscopy evolution seems to remain distant, with further improvement of endoscopes and ancillary instruments, and robot-assisted ureteroscopy representing only some of the areas in which future developments are possible.