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Davis NF, Tzelves L, Geraghty R, Lombardo R, Yuan C, Petrik A, Neisius A, Gambaro G, Jung H, Shepherd R, Tailly T, Somani B, Skolarikos A. 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. Eur Urol Focus 2023; 9:938-953. [PMID: 37277273 DOI: 10.1016/j.euf.2023.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/25/2023] [Accepted: 05/23/2023] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Niall F Davis
- Department of Urology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Lazaros Tzelves
- Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece; Department of Urology/Uro-oncology, University College of London Hospitals NHS Trust, London, UK
| | - Robert Geraghty
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Riccardo Lombardo
- Department of Urology ,Sant' Andrea Hospital, Sapienza University, Rome, Italy
| | - Cathy Yuan
- Division of Gastroenterology, McMaster University and Cochrane UGPD Group, Hamilton, Canada
| | - Ales Petrik
- First Faculty of Medicine, Charles University, Prague, Czechia
| | - Andrea Neisius
- Department of Urology, Bruederkrankenhaus Trier, Johannes Gutenberg University, Mainz, Germany
| | - Giovanni Gambaro
- Department of Medicine, Nephrology and Dialysis Unit, University of Verona, Verona, Italy
| | - Helene Jung
- Department of Urology, Lillebaelt and Vejle Hospitals, University of Southern Denmark Odense, Denmark
| | - Robert Shepherd
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Thomas Tailly
- Department of Urology, University Hospital Ghent, Ghent, Belgium
| | - Bhaskar Somani
- Department of Urology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Andreas Skolarikos
- Department of Urology, Sismanogleio Hospital, National and Kapodistrian University of Athens, Athens, Greece.
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Laranjo Tinoco C, Coutinho A, Cardoso A, Araújo AS, Matos R, Anacleto S, Mota P. Efficacy and safety of fluoroless ureteroscopy and retrograde intrarenal surgery for the treatment of urolithiasis: A comparative study. Actas Urol Esp 2023; 47:535-542. [PMID: 37207987 DOI: 10.1016/j.acuroe.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 05/21/2023]
Abstract
INTRODUCTION Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are traditionally guided by fluoroscopy, but the risks of exposure to ionizing radiation may present a matter of concern for patients and urologists. The aim of this study was to evaluate the efficacy and safety of fluoroless URS and RIRS compared with conventional fluoroscopy-guided procedures for the treatment of ureteral and renal stones. MATERIAL AND METHODS Patients treated with URS or RIRS for urolithiasis between August 2018 and December 2019 were retrospectively evaluated and grouped according to the use of fluoroscopy. Data was collected from individual patient records. The main outcomes were stone-free rate (SFR) and complications, compared between the fluoroscopy and fluoroless groups. A subgroup analysis by type of procedure (URS and RIRS) and a multivariate analysis to identify predictors of residual stones were conducted. RESULTS A total of 231 patients met the inclusion criteria: 120 (51.9%) in the conventional fluoroscopy group and 111 (48.1%) in the fluoroless group. No significant differences were found between groups regarding SFR (82.5% vs 90.1%, p=.127) or postoperative complication rate (35.0% vs 31.5%, p=.675). In the subgroup analysis these variables did not present significant differences, regardless of the procedure considered. In the multivariate analysis the fluoroless technique was not an independent predictor of residual lithiasis (OR 0.991; 95% IC 0.407-2.411; p=.983), when adjusted for procedure type, stone size and stone number. CONCLUSION URS and RIRS can be done without fluoroscopic guidance in selected cases, without affecting the efficacy or safety of the procedure.
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Affiliation(s)
| | - A Coutinho
- Urology Department, Hospital de Braga, Braga, Portugal
| | - A Cardoso
- Urology Department, Hospital de Braga, Braga, Portugal
| | - A S Araújo
- Urology Department, Hospital de Braga, Braga, Portugal
| | - R Matos
- Urology Department, Hospital de Braga, Braga, Portugal
| | - S Anacleto
- Urology Department, Hospital de Braga, Braga, Portugal
| | - P Mota
- Urology Department, Hospital de Braga, Braga, Portugal; School of Medicine, University of Minho, Braga, Portugal; Centro Clínico Académico (2CA-Braga), Braga, Portugal
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Huettenbrink C, Hitzl W, Distler F, Ell J, Ammon J, Pahernik S. Personalized Prediction of Patient Radiation Exposure for Therapy of Urolithiasis: An Application and Comparison of Six Machine Learning Algorithms. J Pers Med 2023; 13:jpm13040643. [PMID: 37109029 PMCID: PMC10146849 DOI: 10.3390/jpm13040643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
The prediction of radiation exposure is an important tool for the choice of therapy modality and becomes, as a component of patient-informed consent, increasingly important for both surgeon and patient. The final goal is the implementation of a trained and tested machine learning model in a real-time computer system allowing the surgeon and patient to better assess patient's personal radiation risk. In summary, 995 patients with ureterorenoscopy over a period from May 2016 to December 2019 were included. According to the suggestions based on actual literature evidence, dose area product (DAP) was categorized into 'low doses' ≤ 2.8 Gy·cm2 and 'high doses' > 2.8 Gy·cm2 for ureterorenoscopy (URS). To forecast the level of radiation exposure during treatment, six different machine learning models were trained, and 10-fold crossvalidated and their model performances evaluated in training and independent test samples. The negative predictive value for low DAP during ureterorenoscopy was 94% (95% CI: 92-96%). Factors influencing the radiation exposure were: age (p = 0.0002), gender (p = 0.011), weight (p < 0.0001), stone size (p < 0.000001), surgeon experience (p = 0.039), number of stones (p = 0.0007), stone density (p = 0.023), use of flexible endoscope (p < 0.0001) and preoperative stone position (p < 0.00001). The machine learning algorithm identified a subgroup of patients of 81% of the total sample, for which highly accurate predictions (94%) were possible allowing the surgeon to assess patient's personal radiation risk. Patients without prediction (19%), the medical expert can make decisions as usual. Next step will be the implementation of the trained model in real-time computer systems for clinical decision processes in daily practice.
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Affiliation(s)
- Clemens Huettenbrink
- Department of Urology, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Wolfgang Hitzl
- Team Biostatistics and Publication of Clinical, Research and Innovation Management (RIM), Trial Studies, Paracelsus Medical University, 5020 Salzburg, Austria
- Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Florian Distler
- Department of Urology, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Jascha Ell
- Department of Urology, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Josefin Ammon
- Institute of Medical Physics, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Sascha Pahernik
- Department of Urology, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
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Miller DT, Semins MJ. Safety During Ureteroscopy: Radiation, Eyes, and Ergonomics. Front Surg 2021; 8:737337. [PMID: 34778359 PMCID: PMC8580849 DOI: 10.3389/fsurg.2021.737337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
It is known that urologic surgeons are at risk of work-place injury due to the physical requirements of operating and exposure to hazards. These hazards include radiation, exposure to body fluids, use of laser energy, and orthopedic injury due to the physical nature of operating. The risks that these hazards present can be mitigated by implementing several evidence-based safety measures. The methods to protect against radiation exposure include keeping radiation usage in the operating room as low as reasonably achievable, donning lead aprons, and wearing protective glasses. Additionally, protective glasses decrease the risk of eye injury from laser injury and exposure to body fluids. Finally, practicing sound surgical ergonomics is essential to minimize the risk of orthopedic injury and promote career longevity. The interventions discussed herein are simple and easy to implement in one's daily practice of urology.
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Affiliation(s)
- David T Miller
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Michelle J Semins
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Miller DT, Semins MJ. Minimizing radiation dose in management of stone disease: how to achieve 'ALARA'. Curr Opin Urol 2021; 31:115-119. [PMID: 33394609 DOI: 10.1097/mou.0000000000000845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Exposure to radiation is known to have adverse effects such as secondary malignancies. Patients with nephrolithiasis are exposed to radiation in the workup and treatment of their condition. Furthermore, exposure to radiation is often repeated due to the high recurrence rate of nephrolithiasis. RECENT FINDINGS We discuss practices inside and outside of the operating room to strive to keep radiation exposure as low as reasonably achievable (ALARA) for patients being treated for nephrolithiasis. These efforts include reduced dose computed tomography scans, fluoroless surgical techniques and new alternative technologies. SUMMARY Maintaining radiation exposure ALARA for our patients is increasingly practical. The urologist must make every effort to adhere to ALARA principles to protect patients from the stochastic effects of radiation.
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Affiliation(s)
- David T Miller
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Subiela JD, Kanashiro A, Emiliani E, Villegas S, Sánchez-Martín FM, Millán F, Palou J, Angerri O. Systematic Review and Meta-Analysis Comparing Fluoroless Ureteroscopy and Conventional Ureteroscopy in the Management of Ureteral and Renal Stones. J Endourol 2020; 35:417-428. [PMID: 33076706 DOI: 10.1089/end.2020.0915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Context: Stone recurrence is frequent in stone formers, and repeated diagnostic and therapeutic procedures in recurrent stone formers place patients and urologists at a significant risk of radiation-related effects. Objective: To assess the efficacy and safety of fluoroless ureteroscopy (fURS) compared with conventional ureteroscopy (cURS) in the management of ureteral and renal stones. Evidence Acquisition: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies providing data on the stone-free rate (SFR), secondary procedures, operative time (OT), and complication rate for fURS and cURS were included. An overall analysis and a subgroup analysis based on the stone target (ureteral stones, renal stones, or a combination thereof) were performed. Evidence Synthesis: A total of 23 studies were included, recruiting 4029 patients. Pooled data showed that in comparison with cURS, fURS exhibited a similar SFR (odds ratio [OR]: 0.99; 95% confidence interval [CI]: 0.92 to 1.06; p = 0.709), without significant differences in overall intraoperative complication rate (OR: 0.73; 95% CI: 0.33 to 1.63; p = 0.446), overall postoperative complication rate (OR: 0.98; 95% CI: 0.59 to 1.63; p = 0.949), major postoperative complication rate (Clavien ≥3; OR: 0.46; 95% CI: 0.14 to 1.53; p = 0.205), OT (standardized mean difference [SMD]: 0.07; 95% CI: -0.15 to 0.29; p = 0.537), hospital stay (SMD: -0.12; 95% CI: -0.26 to 0.02; p = 0.084), or secondary procedures (OR: 1.20; 95% CI: 0.58 to 2.49; p = 0.616). The subgroup analysis revealed no differences in outcomes according to the stone target. We also identified a rate of conversion to the conventional technique of 5% (95% CI: 3% to 7%). Conclusions: The available data suggest that for the treatment of ureteral and renal stones, fURS offers a similar SFR to that provided by the cURS without any increase in complication rate, OT, hospital stay, or secondary procedures. Critical review of the dogmatic routine use of fluoroscopy during ureteroscopy may be warranted.
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Affiliation(s)
- José Daniel Subiela
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrés Kanashiro
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Estaban Emiliani
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergio Villegas
- Urology Service, Hospital Central Universitario Antonio María Pineda, Barquisimeto, Venezuela
| | | | - Felix Millán
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Palou
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Angerri
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
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