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Gull S, Para SA, Singh S, Ansari FM, Kumar M, Ashraf W. Safety and Efficacy of Ureteroscopic Laser Lithotripsy in the Management of Ureteric Calculi in Pregnancy-Experience of a Tertiary Care Center. J Obstet Gynaecol India 2024; 74:131-135. [PMID: 38707872 PMCID: PMC11065790 DOI: 10.1007/s13224-023-01889-y] [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: 01/04/2023] [Accepted: 10/15/2023] [Indexed: 05/07/2024] Open
Abstract
Introduction Ureteric colic in pregnancy is one of the common non-obstetric reasons for emergency department visits. Ureteric calculi present a significant threat to maternal and fetal health and definitive management often becomes necessary. Our aim is to assess the safety and efficacy of ureteroscopic laser lithotripsy in the management of ureteric stones in pregnancy. Material and methods This is a prospective observational study of 3 years carried at a tertiary referral center. It includes all pregnant patients who underwent ureteroscopic laser lithotripsy for ureteric stones. Results A total of 29 pregnant patients underwent ureteroscopic laser lithotripsy at our center in 3 years. The mean age of patients was 33.5 ± 6.2 years, and the mean gestation age at the time of ureteroscopy was 23.34 ± 5.9 weeks. The average stone size was 8.3 ± 3.6 mm and was predominantly found in upper ureter (62%). The mean operative time was 31 ± 8.9 min, and the average laser energy spent was 4.3 ± 1.1 kJ/case. There was no major Intraoperative complication, and the average hospital stay was 2.5 ± 1.5 days. Complete stone clearance was achieved in 93.1% of cases. Conclusion Ureteroscopic laser lithotripsy is safe and effective treatment of ureteric stones in terms of obstetric outcome and stone clearance in pregnancy.
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Affiliation(s)
- Shayista Gull
- Department of Gynecology and Obstetrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, 190011 India
| | - Sajad Ahmad Para
- Department of Urology, Sher-i-Kashmir Institute of Medical Sciences, c- quarter Soura, Srinagar, 190011 India
| | - Shashank Singh
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, 190011 India
| | | | - Manjul Kumar
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, 190011 India
| | - Waseem Ashraf
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, 190011 India
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Haghpanah A, Kamran H, Irani D, Kohansal E, Rahmanian M, Defidio L, Dehghani A, Jahanabadi Z, Askarpour MR. Has the COVID-19 pandemic affected ureteral stone management in pregnant women? A retrospective single-center study. Urologia 2023:3915603231216154. [PMID: 38142409 DOI: 10.1177/03915603231216154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
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.
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Affiliation(s)
- Abdolreza Haghpanah
- Endourology Ward, Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
- Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hooman Kamran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Dariush Irani
- Endourology Ward, Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Erfan Kohansal
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Rahmanian
- Medical School, MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Anahita Dehghani
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Jahanabadi
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
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Dean NS, Krambeck AE. Contemporary Use of Computed Tomography (CT) Imaging in Suspected Urolithiasis in Pregnancy. Curr Urol Rep 2023; 24:443-449. [PMID: 37314612 DOI: 10.1007/s11934-023-01171-8] [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] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
PURPOSE OF REVIEW We aimed to examine the role of low-dose CT (LDCT) in the diagnostic work-up for suspected urolithiasis in pregnancy. We reviewed contemporary urologic recommendations for CT in pregnancy, its utilization for suspected urolithiasis, and explored barriers to its use. RECENT FINDINGS National urologic guidelines and the American College of Obstetricians and Gynecologists recommend the judicious use of LDCT imaging in pregnancy when necessary. We noted inconsistencies in review article management pathways and recommendations for CT imaging for suspected urolithiasis in pregnancy. Overall CT utilization in pregnancy for suspected urolithiasis is low. Proposed barriers to LDCT use in pregnancy include fears of litigation and misperceptions of the harm of diagnostic radiation. Recent advancements in imaging technologies for urolithiasis in pregnancy are limited. More specific diagnostic pathway recommendations from national urologic guideline bodies for when to use LDCT to investigate renal colic in pregnancy may reduce diagnostic and intervention delays.
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Affiliation(s)
- Nicholas S Dean
- Department of Urology, Northwestern University, 676 N. St. Clair, Suite 2300, Chicago, IL, 60611, United States.
| | - Amy E Krambeck
- Department of Urology, Northwestern University, 676 N. St. Clair, Suite 2300, Chicago, IL, 60611, United States
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Bozkurt M, Seker KG, Erkoc M, Danis E, Can O, Degirmentepe RB, Canat HL. Value of neutrophil-to-lymphocyte ratio in predicting surgical intervention for hydronephrosis during pregnancy. Urologia 2022:3915603221135319. [DOI: 10.1177/03915603221135319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background: We aimed to examine the hematological parameters of pregnant patients with ureteral stones that require intervention. Methods: Medical data of patients presenting to urology department between October 2018 and December 2020 were retrospectively analyzed. Patients with flank pain associated with hydronephrosis were included in the study and divided into two groups according to whether an intervention was performed or not (Group-1, Group-2). Ureterorenoscopy (URS) or ureteral stent placement was performed as intervention. Demographic data, complete blood count (CBC), urine analysis, and ultrasonographic findings were collected. Gestational age (week), number of pregnancies, maternal age (years), Anteroposterior pelvis diameter (mm), VAS (Visual Analog Scale) (range 1–10) and mean platelet volume (MPV) were collected from the patient file. Inflammatory markers including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were computed. Results: About 35 patients were included in Group-1 and 52 patients in Group-2. Ureterorenoscopy was performed in 21/35 (60%) patients, and ureteral stents were placed in 14/35 (40%) patients. None of the patients experienced complications. There was no statistical difference between these two groups in terms of maternal age, gestational age, number of pregnancies, pelvis diameter, PLR, and MPV. VAS and NLR were statistically higher in group-1 ( p < 0.05). According to the Receiver operating characteristic curve analysis performed for the prediction of ureteral stone presence, the best cut-off point for the NLR 4.153 (sensitivity 80%, specificity 80.6%, area under curve (AUC): 0.824). Conclusions: We think that NLR can be used to determine the group that needs to be intervented due to ureteral stones in patients with symptomatic hydronephrosis during pregnancy.
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Affiliation(s)
- Muammer Bozkurt
- Department of Urology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Mustafa Erkoc
- Department of Urology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Eyyup Danis
- Department of Urology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Osman Can
- Department of Urology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | | | - Halil Lütfi Canat
- Department of Urology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Morgan K, Rees CD, Shahait M, Craighead C, Connelly ZM, Ahmed ME, Khater N. Urolithiasis in pregnancy: Advances in imaging modalities and evaluation of current trends in endourological approaches. Actas Urol Esp 2022; 46:259-267. [PMID: 35551890 DOI: 10.1016/j.acuroe.2022.03.005] [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: 06/18/2021] [Accepted: 06/27/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Given the challenges involved in diagnosis and treatment of pregnant women with urolithiasis, we aim to review the imaging modalities and current endourological management of these patients. MATERIALS AND METHODS We performed a review of the available literature on urolithiasis in pregnancy. This included evaluation, diagnostic imaging, and therapeutic options. The databases we searched from included Google Scholar and PubMed. A total of 346 abstracts were screened. After our inclusion/exclusion criteria were met, we were left with 42 sources: 18 retrospective studies, 10 reviews/meta-analyses, 8 sets of guidelines, 5 randomized control trials, and 1 prospective cohort. RESULTS We begin our review with the literature available on the safety and efficacy of imaging modalities in the surgical planning for urolithiasis in pregnant patients. This includes renal ultrasound, abdominal x-ray, computed tomography scan, and magnetic resonance imaging. While computed tomography may result in an added radiation exposure, with possible safety concerns, magnetic resonance imaging seems to be safer, however a less sensitive test. We next describe safety, efficacy, and outcomes of various surgical interventions for urolithiasis in pregnant patients. This encompasses ureteral stenting, percutaneous nephrostomy, ureteroscopy, extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. Ureteroscopy is a safer approach, but percutaneous nephrolithotomy offers higher stone-free rates. Using an evidence-based approach, we propose an algorithm for management of the pregnant women with renal colic. CONCLUSION Management of the pregnant women with suspected urolithiasis is a unique challenge for healthcare providers. A multi-disciplinary approach should be taken to optimize outcomes through an evidence-based approach.
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Affiliation(s)
- K Morgan
- Department of Urology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - C D Rees
- Louisiana State University Health Sciences Center, School of Medicine Shreveport, LA, USA
| | - M Shahait
- Department of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - C Craighead
- Louisiana State University Health Sciences Center, School of Medicine Shreveport, LA, USA
| | - Z M Connelly
- Louisiana State University Health Sciences Center, School of Medicine Shreveport, LA, USA
| | - M E Ahmed
- Department of Urology, Mayo Clinic, Rochester, USA
| | - N Khater
- Department of Urology, Louisiana State University Health Sciences Center, Shreveport, USA.
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Keenan RA, Hegarty N, Davis N. Symptomatic hydronephrosis and ureteric calculi in pregnancy - a narrative review with a proposed management protocol. J Endourol 2022; 36:1099-1112. [DOI: 10.1089/end.2021.0876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert Anthony Keenan
- Beaumont Hospital, 57978, Transplant, Urology & Nephrology, Beaumont Hospital, Dublin, Ireland
| | - Nicholas Hegarty
- Mater Misericordiae University Hospital, 8881, Urology, Dublin, Ireland
| | - Niall Davis
- Royal College of Surgeons in Ireland, 8863, Dublin, Ireland
- Beaumont Hospital, 57978, Transplant, Urology & Nephrology, Dublin, Ireland
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Morgan K, Rees C, Shahait M, Craighead C, Connelly Z, Ahmed M, Khater N. Urolitiasis en el embarazo: avances en las modalidades de imagen y evaluación de las tendencias actuales en los abordajes endourológicos. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Karanam S, Kumar A, Tyagi AY, Sharma T, Suchitra MM, Siva KV. Changes in renal function following per cutaneous nephro lithotomy in chronic kidney disease patients with symptomatic renal calculus disease. JOURNAL OF DR. NTR UNIVERSITY OF HEALTH SCIENCES 2022. [DOI: 10.4103/jdrntruhs.jdrntruhs_150_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Management of Kidney Stone Disease in Pregnancy: A Practical and Evidence-Based Approach. Curr Urol Rep 2022; 23:263-270. [PMID: 36197640 PMCID: PMC9732063 DOI: 10.1007/s11934-022-01112-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
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.
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Talwar HS, Panwar VK, Ghorai RP, Mittal A. Catastrophic complications of urolithiasis in pregnancy. BMJ Case Rep 2021; 14:14/5/e241597. [PMID: 34059543 DOI: 10.1136/bcr-2021-241597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Urolithiasis is the most common non-obstetric complication in pregnancy and has the potential to cause grave consequences resulting in pregnancy loss. We present two such cases. First, a 24-year-old woman, 5 weeks pregnant with a history of urolithiasis presented with right flank pain and fever. She was found to have a right perinephric collection and during the course of her treatment suffered an abortion. The second case was a 25-year-old woman who presented in septic shock. She underwent emergency lower segment caesarean section elsewhere 10 days ago for intrauterine death at 38 weeks of gestation. On evaluation, she was found to have bilateral stone disease with a left subcapsular haematoma. Both the cases were managed conservatively and are planned for definitive management. Thus, women of childbearing age with diagnosed urolithiasis should get themselves evaluated and be free of stone disease before planning a family to prevent increased obstetric complications during pregnancy.
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Affiliation(s)
| | - Vikas Kumar Panwar
- Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Rudra Prasad Ghorai
- Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ankur Mittal
- Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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11
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Thakur APS, Sharma V, Ramasamy V, Choudhary A, Patel P, Singh S, Parol S. Management of ureteric stone in pregnancy: a review. AFRICAN JOURNAL OF UROLOGY 2020. [DOI: 10.1186/s12301-020-00070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.
Main body
Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.
Conclusion
There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.
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Dai JC, Nicholson TM, Chang HC, Desai AC, Sweet RM, Harper JD, Sorensen MD. Nephrolithiasis in Pregnancy: Treating for Two. Urology 2020; 151:44-53. [PMID: 32866511 DOI: 10.1016/j.urology.2020.06.097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/12/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To review the literature regarding the epidemiology of stone disease and develop a management algorithm based on current evidence and societal guidelines. METHODS A structured literature review was performed to determine highest quality of evidence guiding care for pregnant patients with symptomatic nephrolithiasis. PUBMED and EMBASE databases were searched using terms "pregnancy," "nephrolithiasis," or "pregnancy" and "renal colic" alone and in combination with "stone", "kidney stone," "ultrasound," "MRI," "CT," "percutaneous nephrostomy," "ureteral stent," or "ureteroscopy." All English-language abstracts were reviewed for relevance and full-length articles were reviewed for content. Articles published prior to 1990 were excluded, and priority for inclusion was given to multi-institutional studies and larger institutional studies, reflecting the highest level of current available evidence and most contemporaneous practice patterns. RESULTS Symptomatic nephrolithiasis affects less than 1% of pregnancies but poses unique diagnostic challenges due to the physiologic changes of pregnancy and risks of ionizing radiation exposure to the fetus. Ultrasound remains the imaging modality of choice. Most patients may be managed non-operatively, but drainage with percutaneous nephrostomy or ureteral stent may be performed if warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment. CONCLUSIONS Though rare, symptomatic nephrolithiasis poses significant clinical challenges due to the need to minimize risk for both mother and fetus with diagnostic and therapeutic interventions. A multi-disciplinary approach is paramount, as is shared decision making with the patient at each step of care.
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Affiliation(s)
- Jessica C Dai
- Department of Urology, University of Washington, Seattle, WA.
| | | | - Helena C Chang
- Department of Urology, Kaiser Permanente Santa Clara Medical Center, Santa Clara CA
| | - Alana C Desai
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Robert M Sweet
- Department of Urology, University of Washington, Seattle, WA
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Valovska MTI, Pais VM. Contemporary best practice urolithiasis in pregnancy. Ther Adv Urol 2018; 10:127-138. [PMID: 29560029 DOI: 10.1177/1756287218754765] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 12/31/2017] [Indexed: 01/10/2023] Open
Abstract
Urolithiasis is the most common nonobstetric complication in the gravid patient. The experience can provoke undue stress for the mother, fetus, and management team. The physiologic changes of pregnancy render the physical exam and imaging studies less reliable than in the typical patient. Diagnosis is further complicated by the need for careful selection of imaging modality in order to maximize diagnostic utility and minimize obstetric risk to the mother and ionizing radiation exposure to the fetus. Ultrasound remains the first-line diagnostic imaging modality in this group, but other options are available if results are inconclusive. A trial of conservative management is uniformly recommended. In patients who fail spontaneous stone passage, treatment may be temporizing or definitive. While temporizing treatments have classically been deemed the gold standard, ureteroscopic stone removal is now acknowledged as a safe and highly effective definitive treatment approach. Ultimately, a multidisciplinary, team-based approach involving the patient, her obstetrician, urologist, radiologist, and anesthesiologist is needed to devise a maximally beneficial management plan.
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Affiliation(s)
| | - Vernon M Pais
- Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, New Hampshire 03756-1000, USA
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15
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Abstract
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.
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Pedro RN, Das K, Buchholz N. Urolithiasis in pregnancy. Int J Surg 2016; 36:688-692. [PMID: 27816709 DOI: 10.1016/j.ijsu.2016.10.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/29/2016] [Indexed: 11/27/2022]
Abstract
Urolithiasis in pregnancy is a major health concern and can potentially affect the well-being of both mother and foetus. Management of this condition often entails simultaneous multidisciplinary involvement of obstetrician, radiologist and urologist. Additionally, adverse effects with usage of anaesthesia, radiation, medications and surgery on mother and foetus, limit utilisation of the full armamentarium of diagnostic and therapeutic modalities that are commonly used in non-pregnant women. This review was conducted using an electronic literature search of peer reviewed journal articles. Clinical studies were identified in the bibliographic database- PubMed (Medline), Ovid and eMedicine(WebMD) using the keywords: hydronephrosis, urolithiasis, kidney stone, urinary tract infection, pregnancy and ultrasound, incidence and epidemiology of renal stones.
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Affiliation(s)
- Renato N Pedro
- U-merge (Urology in Emerging Countries), London, UK; Faculdade Medicina Sao Leopoldo Mandic, Brazil
| | - Krishanu Das
- U-merge (Urology in Emerging Countries), London, UK; Royal Endourology & Robotic Fellow Adelaide Hospital, Australia
| | - Noor Buchholz
- U-merge (Urology in Emerging Countries), London, UK.
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Abstract
Kidney stone imaging is an important diagnostic tool and initial step in deciding which therapeutic options to use for the management of kidney stones. Guidelines provided by the American College of Radiology, American Urological Association, and European Association of Urology differ regarding the optimal initial imaging modality to use to evaluate patients with suspected obstructive nephrolithiasis. Noncontrast CT of the abdomen and pelvis consistently provides the most accurate diagnosis but also exposes patients to ionizing radiation. Traditionally, ultrasonography has a lower sensitivity and specificity than CT, but does not require use of radiation. However, when these imaging modalities were compared in a randomized controlled trial they were found to have equivalent diagnostic accuracy within the emergency department. Both modalities have advantages and disadvantages. Kidney, ureter, bladder (KUB) plain film radiography is most helpful in evaluating for interval stone growth in patients with known stone disease, and is less useful in the setting of acute stones. MRI provides the possibility of 3D imaging without exposure to radiation, but it is costly and currently stones are difficult to visualize. Further developments are expected to enhance each imaging modality for the evaluation and treatment of kidney stones in the near future. A proposed algorithm for imaging patients with acute stones in light of the current guidelines and a randomized controlled trial could aid clinicians.
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Affiliation(s)
- Wayne Brisbane
- Department of Urology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356510, Seattle, Washington 98195, USA
| | - Michael R Bailey
- Center for Industrial and Medical Ultrasound, Applied Physics Laboratory, University of Washington, 1013 NE 40th Street, Seattle, Washington 98105, USA
| | - Mathew D Sorensen
- Department of Urology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356510, Seattle, Washington 98195, USA.,Division of Urology, Department of Veteran Affairs Medical Center, 1660S Columbian Way, Seattle, Washington 98108, USA
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19
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Ordon M, Andonian S, Blew B, Schuler T, Chew B, Pace KT. CUA Guideline: Management of ureteral calculi. Can Urol Assoc J 2015; 9:E837-51. [PMID: 26788233 DOI: 10.5489/cuaj.3483] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The focus of this guideline is the management of ureteral stones. Specifically, the topics covered include: conservative management, medical expulsive therapy, active intervention with either shockwave lithotripsy (SWL) or ureteroscopy (URS), factors affecting SWL treatment success, optimizing success, and special considerations (e.g., pregnancy, urinary diversion). By performing extensive literature reviews for each topic evaluated, we have generated an evidence-based consensus on the management of ureteral stones. The objective of this guideline is to help standardize the treatment of ureteral stones to optimize treatment outcomes.
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Affiliation(s)
- Michael Ordon
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
| | - Sero Andonian
- Division of Urology, Department of Surgery, McGill University, Montreal, QC
| | - Brian Blew
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, ON
| | - Trevor Schuler
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB
| | - Ben Chew
- Department of Urology, University of British Columbia, Vancouver, BC
| | - Kenneth T Pace
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON
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Gomes M, Matias A, Macedo F. Risks to the fetus from diagnostic imaging during pregnancy: review and proposal of a clinical protocol. Pediatr Radiol 2015; 45:1916-29. [PMID: 26271622 DOI: 10.1007/s00247-015-3403-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 04/25/2015] [Accepted: 06/01/2015] [Indexed: 11/25/2022]
Abstract
Every day, medical practitioners face the dilemma of exposing pregnant or possibly pregnant patients to radiation from diagnostic examinations. Both doctors and patients often have questions about the risks of radiation. The most vulnerable period is between the 8th and 15th weeks of gestation. Deterministic effects like pregnancy loss, congenital malformations, growth retardation and neurobehavioral abnormalities have threshold doses above 100-200 mGy. The risk is considered negligible at 50 mGy and in reality no diagnostic examination exceeds this limit. The risk of carcinogenesis is slightly higher than in the general population. Intravenous iodinated contrast is discouraged, except in highly selected patients. Considering all the possible noxious effects of radiation exposure, measures to diminish radiation are essential and affect the fetal outcome. Nonionizing procedures should be considered whenever possible and every radiology center should have its own data analysis on fetal radiation exposure. In this review, we analyze existing literature on fetal risks due to radiation exposure, producing a clinical protocol to guide safe radiation use in a clinical setting.
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Affiliation(s)
- Mafalda Gomes
- Faculty of Medicine, University of Porto, Praça de Gomes Teixeira, 4099-002, Porto, Portugal.
| | - Alexandra Matias
- Faculty of Medicine, University of Porto, Praça de Gomes Teixeira, 4099-002, Porto, Portugal
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Masselli G, Derme M, Bernieri MG, Polettini E, Casciani E, Monti R, Laghi F, Framarino-Dei-Malatesta M, Guida M, Brunelli R, Gualdi G. Stone disease in pregnancy: imaging-guided therapy. Insights Imaging 2014; 5:691-6. [PMID: 25249333 PMCID: PMC4263802 DOI: 10.1007/s13244-014-0352-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/06/2014] [Accepted: 08/20/2014] [Indexed: 12/02/2022] Open
Abstract
Renal colic is the most frequent nonobstetric cause for abdominal pain and subsequent hospitalization during pregnancy. The physio-anatomical changes in the urinary tract and the presence of the fetus may complicate the clinical presentation and management of nephrolithiasis. Ultrasound (US) is the primary radiological investigation of choice. Magnetic resonance urography (MRU) and low-dose computed tomography (CT) have to be considered as a second- and third-line test, respectively. If a study that uses ionizing radiation has to be performed, the radiation dose to the fetus should be as low as possible. The initial management of symptomatic ureteric stones is conservative during pregnancy. Intervention will be necessary in patients who do not respond to conservative measures. Therefore, it is crucial to obtain a prompt and accurate diagnosis to optimize the management of these patients. Teaching Points • In pregnancy, renal colic is the most frequent nonobstetric cause for abdominal pain and hospitalization. • Magnetic resonance urography should be considered when ultrasound is nondiagnostic. • Low-dose CT should be considered as a last-line test during pregnancy.
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Affiliation(s)
- Gabriele Masselli
- Department Radiology, Università di Roma Sapienza, Viale del Policlinico 155, Rome, 00161, Italy,
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Ong MM, Riffel P, Budjan J, Bolenz C, Schönberg SO, Haneder S. [Oncological diseases and postoperative alterations of the bladder and urinary tract]. Radiologe 2014; 54:1221-34; quiz 1235-6. [PMID: 25425104 DOI: 10.1007/s00117-014-2768-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In the challenging evaluation of upper urinary tract malignancies multidetector computed tomography (CT) has become the standard imaging method. Cross sectional imaging not only allows the detection and visualization of the tumor itself but also provides nodal and metastasis staging in one examination (one-stop-shop). The majority of urothelial carcinomas are located in the urinary bladder. In this case, CT and more recently magnetic resonance imaging (MRI) can also deliver decisive information regarding TNM classification. A combination of clinical, histological, morphological and functional parameters allows both risk stratification and a targeted therapy based on the individual tumor stage.
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Affiliation(s)
- M M Ong
- Institut für Klinische Radiologie und Nuklearmedizin, Medizinische Fakultät Mannheim, Universitätsmedizin Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland,
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Roy C, Ohana M, Host P, Alemann G, Labani A, Wattiez A, Lang H. MR urography (MRU) of non-dilated ureter with diuretic administration: Static fluid 2D FSE T2-weighted versus 3D gadolinium T1-weighted GE excretory MR. Eur J Radiol Open 2014; 1:6-13. [PMID: 26937423 PMCID: PMC4750612 DOI: 10.1016/j.ejro.2014.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 08/04/2014] [Accepted: 08/06/2014] [Indexed: 12/13/2022] Open
Abstract
T2w-MRU with multiple orientations and diuretic is sufficient to identify non-dilated ureter. T2w-MRU offers information on ureteral contractions and could be proposed to detect initial obstruction before hydronephrosis occurs (for instance in cases of endometriosis). T2w-MRU could also be used to evaluate potential renal donors or in patients unable to receive gadolinium. CE-MRU rapidly produces an overdistended bladder with a risk of false positive diagnosis of mild obstruction. CE-MRU is less convenient for patients.
Objective The goal of this prospective study was to compare the efficiency of two types of MRU after diuretic administration to identify the non-dilated ureter. Methods MR pelvic examinations were performed in 126 patients after receiving furosemide. Each patient underwent in addition to their protocol for context, two types of MRU: 2D T2-weighted FSE (T2w-MRU) and 3D Gd T1-weighted GE (CE-MRU). Four segments were checked for each ureter. For the first part of the analysis, readers evaluated the whole image quality using a four points subjective scale and for the second part, they were asked to score separately each ureteral segment as present or absent. Results 1008 ureteral segments were checked. For the image quality, readers did not find any significant difference (3.8 ± 0.5 vs 3.6 ± 0.7, p value: 0.13) between MRU methods. The interobserver agreement was excellent with a κ correlation coefficient as high as 0.89 for T2w-MRU and 0.92 for CE-MRU, respectively. For the detection of the segments and considering the 9 rotations for the T2W MRU, there were no statistically significant differences between the two groups. Conclusion T2-weighted MRU with multiple orientations and diuretic is sufficient to identify the non-dilated ureter. It offers information on ureteral peristaltism. It can be suggested that this sequence is able to detect an initial obstruction before hydronephrosis occurs.
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Affiliation(s)
- C Roy
- Department of Radiology B, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - M Ohana
- Department of Radiology B, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - Ph Host
- Department of Radiology B, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - G Alemann
- Department of Radiology B, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - A Labani
- Department of Radiology B, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - A Wattiez
- Department of Gynecology - University Hospital of Strasbourg - Hospital Hautepierre, 1, place de l'hopital BP 426, 67091 Strasbourg Cedex, France
| | - H Lang
- Department of Urology, University Hospital of Strasbourg - New Civil Hospital, 1, place de l'hôpital BP 426, 67091 Strasbourg Cedex, France
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Abstract
Diagnosis and treatment of renal stones during pregnancy is a complex problem. Risks to the fetus from ionising radiation and interventional procedures need to be balanced with optimising clinical care for the mother. Management of such patients requires a clear understanding of available options, with a multidisciplinary team approach. In this review, we discuss the role of different diagnostic tests including ultrasound, magnetic resonance urography, and computerized tomography. We also provide an update on recent developments in the treatment of renal stones during pregnancy. Expectant management remains first-line treatment. Where definitive treatment of the stone is required, new evidence suggests that ureteroscopic stone removal may be equally safe, and possibly better than traditional temporising procedures.
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Cabrera F, Preminger GM, Lipkin ME. As low as reasonably achievable: Methods for reducing radiation exposure during the management of renal and ureteral stones. Indian J Urol 2014; 30:55-9. [PMID: 24497684 PMCID: PMC3897055 DOI: 10.4103/0970-1591.124208] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Imaging for urolithiasis has evolved over the past 30 years. Currently, non-contrast computed tomography (NCCT) remains the first line imaging modality for the evaluation of patients with suspected urolithiasis. NCCT is a dominant source of ionizing radiation for patients and one of its major limitation. However, new low dose NCCT protocols may help to reduce the risk. Fluoroscopy use during operating room (OR) surgical procedures can be a substantial source of radiation for patients, OR staff and surgeons. It is important to consider the amount of radiation patients are exposed to from fluoroscopy during operative interventions for stones. Radiation reduction can be accomplished by appropriate selection of imaging studies and multiple techniques, which minimize the use of fluoroscopy whenever possible. The purpose of this manuscript is to review common imaging modalities used for diagnosing and management of renal and ureteral stones associated with radiation exposure. We also review alternatives and techniques to reduce radiation exposure.
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Affiliation(s)
- Fernando Cabrera
- Duke Comprehensive Kidney Stone Center, Department of Urology, Duke University Medical Center, Durham, North Carolina, USA
| | - Glenn M Preminger
- Duke Comprehensive Kidney Stone Center, Department of Urology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael E Lipkin
- Duke Comprehensive Kidney Stone Center, Department of Urology, Duke University Medical Center, Durham, North Carolina, USA
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Semins MJ, Matlaga BR. Kidney stones and pregnancy. Adv Chronic Kidney Dis 2013; 20:260-4. [PMID: 23928391 DOI: 10.1053/j.ackd.2013.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 01/16/2013] [Accepted: 01/18/2013] [Indexed: 12/18/2022]
Abstract
Kidney stones are common and do not spare the pregnant population. Although a simple stone event is usually straightforward in the general population, it is complex during pregnancy. Acute nephrolithiasis is associated with a unique set of complications during pregnancy and, because of imaging limitations, diagnosis is challenging. Multidisciplinary care is the key in proper management decisions. The pathophysiology of kidney stone formation in the pregnant state is also unique. Herein, we discuss the complexity of kidney stones and pregnancy.
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Lipkin ME, Preminger GM. Imaging techniques for stone disease and methods for reducing radiation exposure. Urol Clin North Am 2012. [PMID: 23177634 DOI: 10.1016/j.ucl.2012.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Imaging plays a critical role in the evaluation of patients with urolithiasis. It is essential for the diagnosis of stones and provides important information to aide in determining the appropriate treatment of renal or ureteral calculi. Imaging for urolithiasis has evolved over the past 30 years. Currently, noncontrast computed tomography remains the first-line imaging modality for the evaluation of patients with suspected urolithiasis. Proper imaging modality selection helps to minimize radiation exposure. Following the principles of As Low As Reasonably Achievable in the operating room can help reduce the amount of radiation patients are exposed to from fluoroscopy.
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Affiliation(s)
- Michael E Lipkin
- Department of Urology, Duke University Medical Center, DUMC 3167, Durham, NC 27710, USA.
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