X-ray-free ultrasound-guided versus fluoroscopy-guided percutaneous nephrolithotomy: a comparative study with historical control

Comparison of Treatment Outcomes for Fluoroscopic and Fluoroscopy-free Endourological Procedures: A Systematic Review on Behalf of the European Association of Urology Urolithiasis Guidelines Panel

CONTEXT

Endourological procedures frequently require fluoroscopic guidance, which results in harmful radiation exposure to patients and staff. One clinician-controlled method for decreasing exposure to ionising radiation in patients with urolithiasis is to avoid the use of intraoperative fluoroscopy during stone intervention procedures.

OBJECTIVE

To comparatively assess the benefits and risks of "fluoroscopy-free" and fluoroscopic endourological interventions in patients with urolithiasis.

EVIDENCE ACQUISITION

A systematic review of the literature from 1970 to 2022 was performed using the MEDLINE/PubMed, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov. Primary outcomes assessed were complications and the stone-free rate (SFR). Studies reporting data on ureteroscopy and percutaneous nephrolithotomy (PCNL) were eligible for inclusion. Secondary outcomes were operative duration, hospital length of stay, conversion from a fluoroscopy-free to a fluoroscopic procedure, and requirement for an auxiliary procedure to achieve stone clearance.

EVIDENCE SYNTHESIS

In total, 24 studies (12 randomised and 12 observational) out of 834 abstracts screened were eligible for analysis. There were 4564 patients with urolithiasis in total, of whom 2309 underwent a fluoroscopy-free procedure and 2255 underwent a comparative fluoroscopic procedure for treatment of urolithiasis. Pooled analysis of all procedures revealed no significant difference between the groups in SFR (p = 0.84), operative duration (p = 0.11), or length of stay (p = 0.13). Complication rates were significantly higher in the fluoroscopy group (p = 0.009). The incidence of conversion from a fluoroscopy-free to a fluoroscopic procedure was 2.84%. Similar results were noted in subanalyses for ureteroscopy (n = 2647) and PCNL (n = 1917). When only randomised studies were analysed (n = 12), the overall complication rate was significantly in the fluoroscopy group (p < 0.001).

CONCLUSIONS

For carefully selected patients with urolithiasis, fluoroscopy-free and fluoroscopic endourological procedures have comparable stone-free and complication rates when performed by experienced urologists. In addition, the conversion rate from a fluoroscopy-free to a fluoroscopic endourological procedure is low at 2.84%. These findings are important for clinicians and patients, as the detrimental health effects of ionising radiation are negated with fluoroscopy-free procedures.

PATIENT SUMMARY

We compared treatments for kidney stones with and without the use of radiation. We found that kidney stone procedures without the use of radiation can be safely performed by experienced urologists in patients with normal kidney anatomy. These findings are important, as they indicate that the harmful effects of radiation can be avoided during kidney stone surgery.

Ultrasound versus fluoroscopy as imaging guidance for percutaneous nephrolithotomy: A systematic review and meta-analysis

OBJECTIVES

To determine whether the outcomes of ultrasound-guided percutaneous nephrolithotomy (UG-PCNL), an alternative to traditional fluoroscopy-guided percutaneous nephrolithotomy (FG-PCNL), are comparable.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library was carried out to discover investigations comparing UG-PCNL to FG-PCNL, and accordingly, a meta-analysis of those studies was performed. The primary outcomes included the stone-free rate (SFR), overall complications based on Clavien-Dindo classification, duration of surgery, duration of patients' hospitalization, and hemoglobin (Hb) drop during the surgery. All statistical analyses and visualizations were implemented utilizing R software.

RESULTS

Nineteen studies, including eight randomized clinical trials (RCTs) and eleven observational cohorts, comprising 3016 patients (1521 UG-PCNL patients) and comparing UG-PCNL with FG-PCNL met the inclusion criteria of the current study. Considering SFR, overall complications, duration of surgery, duration of hospitalization, and Hb drop, our meta-analysis revealed no statistically significant difference between UG-PCNL and FG-PCNL patients, with p-values of 0.29, 0.47, 0.98, 0.28, and 0.42, respectively. Significant differences were discovered between UG-PCNL and FG-PCNL patients in terms of the length of time they were exposed to radiation (p-value< 0.0001). Moreover, FG-PCNL had shorter access time than UG-PCNL (p-value = 0.04).

CONCLUSION

UG-PCNL provides the advantage of requiring less radiation exposure while being just as efficient as FG-PCNL; thus, this study suggests prioritizing the use of UG-PCNL.

Advances in percutaneous renal puncture: a comprehensive review of the literature

PURPOSE OF REVIEW

Percutaneous nephrolithotomy (PCNL) constitutes the gold standard procedure for patients suffering from more than 2 cm renal stones. The puncture is a very critical step of PCNL, affecting manoeuvrability of the nephroscope, possibility to remove stone fragments, risk of bleeding and radiation exposure. The aim of the current review was to discuss the advances in percutaneous renal puncture.

RECENT FINDINGS

Following technological evolution in medicine, there was a consistent development in the puncture techniques, aiming at the improvement of its efficacy and safety. The use of specific agents can improve ultrasonic guidance, making the challenging step of gaining access to the kidney easier for the experienced surgeon and more accessible for the resident urologist. Future developments in the electromagnetic and three-dimensional (3D) technology may establish a high level of accuracy with decreased rates of related complications, even in the hands of beginners.

SUMMARY

The advances in percutaneous puncture can lead to improved safety and accuracy of this procedure decreasing the radiation exposure and the complication rate.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

Comparison between prone and supine nephrolithotomy in pediatric population: a double center experience

PURPOSE

Stone disease in the pediatric age is an increasing issue. Percutaneous Nephrolithotomy (PNL) can be used for larger and complex stones. As in adults it can be performed in the supine or prone position.

METHODS

We retrospectively reviewed two centers' experience in prone and supine PNL in children to analyze its results and complications.

RESULTS

33 patients underwent prone and 19 supine procedures. Patients in the prone group were younger than in the supine, while no significant differences were found in stone burden, access size, operative time or complications. Complications were: 8 and 4 Clavien 1 for the prone and supine group, respectively, one case of urosepsis (4b) in the prone and 2 cases of Clavien 3 in the supine group (double J stent placement for renal colic and ureteroscopy for steinstrasse). Tubeless procedures and mean nephrostomy time were in favor of the supine group, whereas fluoroscopy time and ureteral drainage stay were in support of the prone group. Stone free rate was better in the supine group (83.3 vs 66.6%), possibly reflecting the capability to perform a combined approach in 12 patients (allowing to reach all the calyx with simultaneous anterograde and retrograde access) or younger age in the prone group (13 vs 2 patients ≤5 years), with no differences in stone burden.

CONCLUSIONS

Supine approach seems to guarantee higher stone-free rates. Larger series are necessary to determine what the best technique is in terms of X-ray exposure, operative time and complications.

X-Ray-Free Endoscopic Combined Intrarenal Surgery for Complex Proximal Ureteral Stone: A Case Report

X-ray-free endoscopic combined intra renal surgery (ECIRS) is a feasible alternative to avoid radiation exposure to both surgical teams and patients, but has not been reported prior. The aim of this report is to present our first-hand experience of performing X-ray-free ECIRS for complex ureteral stone. A 57-year-old female presented with right flank pain, fever, dysuria, and leukocytosis. The computed tomography scan showed right impacted proximal ureteral stone sized 33 ´17 mm and grade IV hydronephrosis. Percutaneous nephrostomy was performed immediately. With improvement of clinical symptoms two days after nephrostomy, X-ray-free ECIRS was performed. The patient was placed in a Galdakao-modified supine position. During ureteroscopy (URS), there was noted right ureteral stenosis in the distal part of the stone, which could be passed. However, the stone was impacted and the semi-rigid URS was not able to push it. Therefore, antegrade approach with percutaneous nephrolithotomy was performed. Previous nephrostomy tract was used as percutaneous access. Tract dilatation was performed under direct visualization from the URS. The 28 Fr rigid nephroscope was used during the ECIRS procedure. The stone was fragmented using shock-pulse lithotripters. There was no residual stone or infundibular laceration after the procedure. A 6 Fr double J stent was inserted retrogradely due to ureteral stenosis. There was no complication during and after the procedure. The patient was discharged on post-operative day three. X-ray free ECIRS for complex proximal ureteral stone was possible and showed good results.