Stone treatment and coagulopathy

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.

The Effect of Pre-Stenting on Bleeding-Related Complications Following Ureteroscopy in Patients on Anticoagulation or Antiplatelet Therapy

Introduction: The American Urological Association guidelines state that continuing anticoagulant (AC) and antiplatelet (AP) agents during ureteroscopy (URS) is safe. Through a multi-institutional retrospective study, we sought to determine whether pre-stenting in patients on AP or AC was associated with fewer URS bleeding-related complications. Methods: A series of 8614 URS procedures performed across three institutions (April 2010 to September 2017) was electronically reviewed for AC/AP use at time of URS. Records indicating AC or AP use at time of URS were then manually reviewed to characterize intraoperative and 30-day postoperative (intraoperative bleeding, postoperative hematuria, emergency department visits, hospital readmission, unplanned reoperation, phone calls, and other minor 30-day complications). Results: A total of 293 identified URS procedures were completed on patients on AC/AP therapy-112 cases were on AC only (38 were pre-stented), 158 on AP only (51 pre-stented), and 23 on both AP and AC (8 pre-stented). Patient characteristics and comorbidities were similar between the pre-stented and non-pre-stented groups. For AC and AP subjects, pre-stenting did not decrease the composite risk of bleeding complications (10.3% pre-stent vs 12.2% non-prestent, p = 0.6). Pre-stented patients did have a significantly lower likelihood of requiring an unplanned reoperation (1.0% vs 5.6%, p = 0.04). In the subgroup of patients on AP alone, pre-stented patients had significantly fewer episodes of intraoperative bleeding (0% vs 9%, p = 0.04), unplanned reoperations (0% vs 6.5%, p = 0.02), and 30-day complications (14% vs 27%, p = 0.05). In the subgroup of patients on AC alone, there were no significant differences in outcomes based on stent status. Conclusions: In this multi-institutional study, we found that pre-stenting before URS was not associated with fewer bleeding complications. However, pre-stenting appeared to be associated with improved outcomes for those patients on AP therapy. These results suggest a need for prospective studies to clarify the role of pre-stenting for URS.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Ureteroscopic and flexible ureteroscopic lithotripsy: continuation or discontinuation of anticoagulant or antiplatelet drugs? A Chinese survey among urologists

PURPOSE

To evaluate the management of antithrombotic drugs made by different urologists before ureteroscopic lithotripsy and flexible ureteroscopy in stone patients undergoing active anticoagulant or antiplatelet therapy.

METHODS

A survey was distributed to 613 urologists in China, which included personal work information and views on the management of anticoagulants (AC) or antiplatelet (AP) drugs during the perioperative period of ureteroscopic lithotripsy (URL) and flexible ureteroscopy (fURS).

RESULTS

20.5% of urologists believed that AP drugs could be continued and 14.7% believed that AC drugs could be continued. 26.1% of the urologists who participated in more than 100 ureteroscopic lithotripsy or flexible ureteroscopy surgeries each year believed that AP drugs could be continued and 19.1% believed that AC drugs could be continued, compared with 13.6% (P < 0.01) and 9.2% (P < 0.01) of the urologists who performed less than 100 surgeries. Among the urologists with more than 20 cases undergoing active AC or AP therapy per year, 25.9% thought that AP drugs could be continued and 19.7% thought that AC drugs could be continued, compared with 17.1% (P = 0.008) and 11.5% (P = 0.005) of the urologists with less than 20 cases.

CONCLUSION

The decision on the continuation of AC or AP drugs before ureteroscopic and flexible ureteroscopic lithotripsy should be individualized. The experience in URL and fURS surgeries and in dealing with patients under AC or AP therapy is the influencing factor.

Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022

PURPOSE

The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis.

MATERIALS AND METHODS

The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology.

RESULTS

The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles.

CONCLUSIONS

This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis.

PATIENT SUMMARY

The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.

Impact of liver disease severity on outcomes of patients undergoing endourological procedures for urolithiasis

Objectives:

This study is aimed to determine the impact of liver disease severity on the outcome of patients undergoing endourological procedures for urolithiasis, and to understand the factors that are helpful in improving the outcome.

Materials and methods:

We retrospectively analyzed the records of patients with chronic liver disease who underwent endourological procedures between January 2014 and February 2020. Inpatient records and charts were assessed for age, sex, height, weight, body mass index, model for end-stage liver disease (MELD) score, Child-Turcotte-Pugh score, type of procedure and anesthesia, intensive care unit (ICU) stay, duration of hospitalization, number, size, and position of stones, and postoperative complications such as hematuria, sepsis, and secondary procedures. Data are presented as mean ± standard deviation or frequency. The chi-square test was applied to determine the exact association between categorical data and Student t-test or Mann-Whitney U test as appropriate for continuous data. Statistical significance was set at p < 0.05.

Results:

Hospital and ICU stay as well as administration of different blood products were significantly longer in the Child C than in the Child A and B categories (p < 0.001). Two patients in the Child C category died, while 3 left the hospital against medical advice. The duration of ICU stay and blood products administered increased with augmenting MELD scores. The durations of hospitalization and blood product administration were significantly higher in patients with an MELD score ≥20 than in the group with MELD score <20.

Conclusions:

Hospital and ICU stay and blood product administration were significantly higher in Child C than in Child A and B class patients. Hospitalization duration and blood product administration were significantly higher in patients with an MELD score ≥20.

Indications and contraindications for shock wave lithotripsy and how to improve outcomes

For over 35 years shock wave lithotripsy has proven to be an effective, safe and truly minimally invasive option for the treatment of nephrolithiasis. Various technical factors as well as patient selection can impact the success of the procedure. We used published work focusing on outcomes of shock wave lithotripsy, risk of complications, and strategies for improving stone fragmentation to create this review. Multiple patient and technical factors have been found to impact success of treatment. Skin to stone distance, stone density and composition, size and location of the stone within the urinary system all influence stone free rates. A slower rate with a gradual increasing voltage, precise targeting, proper coupling will improve stone fragmentation and decrease risk of complications. The selection of appropriate patients through a shared decision making process and attention to the technical factors that improve stone free rates is key to providing an effective treatment and patient satisfaction.

Ureteroscopy in Patients with Bleeding Diatheses, Anticoagulated, and on Anti-Platelet Agents: A Systematic Review and Meta-Analysis of the Literature

INTRODUCTION

Ureteroscopy (URS) is the most common surgical treatment of urolithiasis and can be problematic in patients with a bleeding diathesis. The intent of this review is to systematically review the literature to assess the safety and efficacy of ureteroscopic procedures in these groups of patients.

METHODS

The systematic review was performed according to the Cochrane diagnostic accuracy review guidelines. The search strategy was conducted to perform a comprehensive database search (1990-2017). A cumulative analysis was done and where applicable a comparative analysis between bleeding diathesis patients and those without.

RESULTS

Eight studies included were all published between 1998 and 2016 with the total number of participants with bleeding diatheses being 1109 with an age range of 18-97. Overall stone-free rate across the studies was 90.8% vs 86.2% in the control group. There was no significant difference in complications between the bleeding diathesis group and control group (N = 12,757, p = 0.07, 95% confidence interval [CI] 0.92, 6.02, I₂ = 78%). Pooled analysis for bleeding-related complications shows a statistically significant difference favoring the control arm (N = 12,757, p ≤ 0.0001, 95% CI 1.81, 5.73, I₂ = 0%). Pooled analysis for thrombosis shows no statistically significant difference between the bleeding diathesis group and the control arm (N = 118, p = 0.67, 95% CI 0.23, 9.86, I₂ = 48%).

CONCLUSION

The use of URS with or without the holmium laser is a safe and efficient modality for treating patients with urolithiasis who also have a bleeding diathesis or are anticoagulated or on antiplatelet agents. However, this review would suggest that the increased risk of procedure related bleeding is not insignificant and a patient-centered approach should be taken with regards to continuing these agents or not correcting bleeding diatheses.

A review study to evaluate holmium:YAG laser lithotripsy with flexible ureteroscopy in patients on ongoing oral anticoagulant therapy

The objective of this study was to evaluate the safety and efficacy of flexible ureteroscopy (FURS) and holmium:YAG laser lithotripsy for the treatment of upper urinary tract stones in patients on active oral anticoagulants. The records of 1081 patients who underwent flexible ureteroscopic holmium:YAG (Ho:YAG) laser lithotripsy for upper ureteral and renal calculi from 1999 to 2015 were retrospectively reviewed. A total of 84 patients on continuous oral anticoagulation or antiplatelet therapy (warfarin, aspirin, or clopidogrel) were identified. Of these patients, 40 were on warfarin, 25 on aspirin, 11 on clopidogrel, and 8 on both aspirin and clopidogrel. The drugs were not discontinued. The baseline characteristics, indications for anticoagulation therapy, perioperative data, stone-free rate, and complications were documented. Evaluation of outcomes was assessed at 1-, 3-, and 6-month follow-up postoperatively. Mean stone size was 19.7 ± 9.4 (range 8 to 31 mm). Twenty patients had upper ureteral and 64 patients had intrarenal calculi. Two patients had bilateral renal calculi. Mean operation time was 78.2 ± 23.8 min (range 17 to 144 min). Two procedures (2.3%) in warfarin group were terminated due to persistent bleeding causing visual impairment. No transfusions were required. The mean serum hemoglobin levels did not change significantly (12.9 ± 3.7 to 12.2 ± 3.3 g/dL). No thromboembolic or cardiac adverse events were observed perioperatively. The double-j (DJ) ureteral catheterization time was 29.6 ± 9.3 days (range 14 to 68 days) and the hospital stay was 1.6 ± 0.6 days (range 1 to 4). The stone-free rate was 95.2% (80 patients) at 6 months. Flexible ureteroscopic Ho:YAG laser lithotripsy in patients requiring long-term anticoagulation therapy seems to be a safe and effective procedure and should be considered as a first-line treatment option in such patients for the surgical management of upper urinary tract stones.

Influence of acetylsalicylic acid and low-molecular weight heparins on the formation of renal hematoma after shock wave lithotripsy

PURPOSE

To investigate the risk of renal hematoma (RHT) after shock wave lithotripsy (SWL) among patients on acetylsalicylic acid (ASA) or low-molecular-weight heparin (LMWH).

PATIENTS AND METHODS

Retrospective analysis of 434 patients treated with SWL for nephrolithiasis and ureterolithiasis of the proximal ureter. Primary endpoint was detection of RHT by ultrasound the day after SWL. Secondary outcome variables included transfusion of erythrocyte concentrate(s), interventions, hospital readmission or death due to RHT within 30 days of SWL. Binary logistic regression analysis was used including a post hoc one-way analysis.

RESULTS

Of 434 patients, 33 (7.6%) and 67 (15.4%) patients were medicated with ASA and LMWH, respectively. RHT was detected in 20 of 434 (4.6%) patients. Of those, 3 (20%) were on ASA, 6 (35%) were on LMWH, 1 (5%) was on ASA and LMWH, and 10 (50%) had no anticoagulation. Univariate analysis showed a statistically significant higher risk for RHT among patients on ASA (p = 0.04) and LWMH (p = 0.02) with an untreated urinary tract infection (UTI) (p = 0.008) and history of cardiovascular disease (p = 0.028). On multivariate analysis, ASA medication, untreated UTI (OR 4.4, 95% CI 1.31-14.75, p = 0.016 and OR 5.79, 95% CI 1.65-20.32, p = 0.03) and a therapeutic dose of LMWH (OR 10.4, 95% CI 1.74-62.27, p = 0.01) were independent predictors for RHT.

CONCLUSIONS

Before SWL, a patient risk profile should be evaluated. If feasible, LMWH in therapeutic dosing should be avoided, and ASA should be discontinued. UTI should be treated before SWL in any case.

TRIAL REGISTRATION

http://www.clinicaltrials.gov ; Identifier NCT02875717.

Shockwave lithotripsy: techniques for improving outcomes

OBJECTIVES

Shock wave lithotripsy (SWL) remains the only effective truly non-invasive treatment for nephrolithiasis. While single-treatment success rates may not equal those of ureteroscopy and percutaneous nephrolithotomy, it has an important role to play in the management of stones. In this paper, we outline the latest evidence-based recommendations for maximizing SWL outcomes, while minimizing complications.

MATERIALS AND METHODS

A comprehensive review of the current literature was performed regarding maximizing SWL outcomes.

RESULTS

Several different considerations need to be made regarding patient selection with respect to body habitus, body mass index, anatomical location and underlying urologic abnormalities. Stone composition and stone density (Hounsfield Units) are important prognostic variables. Patient positioning is critical to allow for adequate stone localization with either fluoroscopy or ultrasound. Coupling should be optimized with a low viscosity gel applied to the therapy head first and patient movement should be limited. SWL energy should be increased slowly and shockwave rates of 60 or 90 Hz should be used. Medical expulsive therapy with alpha-blockers after SWL treatment has shown benefit, particularly with stones greater than 10 mm.

CONCLUSION

While single-treatment success rates may not equal those of ureteroscopy or percutaneous nephrolithotomy, with proper patient selection, optimization of SWL technique, and use of adjunctive treatment after SWL, success rates can be maximized while further reducing the already low rate of serious complications. SWL remains an excellent treatment option for calculi even in 2017.

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

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

CUA Guideline: Management of ureteral calculi

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.

Haematological considerations in urology: A systematic review

Deep venous thrombosis (DVT) remains a serious and common complication of surgical procedures and is therefore an issue of importance for all urologists. In the UK, pulmonary embolism (PE) following DVT in hospitalised patients causes 32,000 deaths each year. DVT and PE represent the outcome of venous thromboembolism (VTE). The total cost for management of VTE in 2005 was approximately ₤640 million. Early risk assessment and optimising modifiable risks are paramount in order to reduce the incidence of VTE. In this article we review common risk factors for VTE and emphasise specific risk factors for urological procedures. The perioperative management of urological patients who are chronically anticoagulated is discussed. We review the literature regarding anticoagulation and its relevance to all urological procedures and mention the problems associated with new anticoagulant agents. All urologists should be familiar with the new range of anticoagulant agents due to the increasing number of patients taking them.

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.

[Ureteroscopy: is it the best?]

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery

With populations ageing and active treatment of urinary stones increasingly in demand, more patients with stones are presenting with an underlying bleeding disorder or need for regular thromboprophylaxis, by means of antiplatelet and other medication. A practical guide to thromboprophylaxis in the treatment of urinary tract lithiasis has not yet been established. Patients can be stratified according to levels of risk of arterial and venous thromboembolism, which influence the requirements for antiplatelet and anticoagulant medications, respectively. Patients should also be stratified according to their risk of bleeding. Consideration of the combined risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. The choice of shockwave lithotripsy, percutaneous nephrolithotomy or ureteroscopy with laser lithotripsy for treatment of lithiasis should be determined with regard to these risks. Although ureteroscopy is the preferred method in high-risk patients, shockwave lithotripsy and percutaneous nephrolithotomy can be chosen when indicated, if appropriate guidelines are strictly followed.

Extracorporeal shock wave lithotripsy for management of residual stones after ureterolithotripsy versus mini-percutaneous nephrolithotomy: a retrospective study

Purpose

To compare the efficacy of extracorporeal shock wave lithotripsy in managing residual stones after ureterolithotripsy and mini-percutaneous nephrolithotomy.

Materials and Methods

A retrospective study was carried out of 71 patients with proximal urinary tract stones (greater than 10 mm) who underwent ureterolithotripsy or mini-percutaneous nephrolithotomy at a single institution from 2009 to 2011. The 71 patients were divided into two groups: group I (n = 37) comprised patients who underwent ureterolithotripsy, and group II (n = 34) comprised patients who underwent mini-percutaneous nephrolithotomy. Clinical characteristics, stone-free rates, stone demographics, and complications were evaluated.

Results

The overall stone-free rate was 90.1%. The stone-free rates in groups I and II were 97.3% and 82.4%, respectively. There was a statistically significant difference in the stone-free rates between groups I and II (P = 0.035). Neither serious intraoperative nor postoperative complications were observed. No significant difference in complications was observed between the two groups (P = 0.472).

Conclusions

The results of our study suggest that extracorporeal shock wave lithotripsy is an effective and safe auxiliary procedure for managing residual stones after primary endoscopic surgery. This procedure is associated with a satisfactory stone-free rate and a low complication rate, particularly for residual stones after ureteroscopic procedures.

Flexible ureteroscopy and holmium:YAG laser lithotripsy for stone disease in patients with bleeding diathesis: a systematic review of the literature

INTRODUCTION AND OBJECTIVES

The management of urolithiasis in patients on anticoagulants presents a challenge to the endourologist. Due to multiple comorbidities, it may be impossible to safely discontinue the anticoagulant treatment. Other modalities such as shock wave lithotripsy and PCNL are contraindicated in these patients, so ureteroscopic treatment may be the only option. We conducted a systematic review of the literature to look at the safety and efficacy of ureteroscopic management in these patients.

METHODS

Systematic review and quantitative meta-analysis was performed using studies identified by a systematic electronic literature search from January 1990 to August 2011. All articles reporting on treatment for stones in patients with a bleeding diathesis using ureteroscopy and a Holmium:YAG laser were included. Two reviewers independently extracted the data from each study. The data was included into a meta-analysis and discussed.

RESULTS

Three studies were identified reporting on 70 patients (73 procedures). All patients had stone fragmentation using Holmium laser. The mean stone size was 13.2mm with a range of 5-35 mm. The quality of the included studies was modest. Stone free status was achieved in sixty-four patients (87.7%). There were no major complications and only 11% of the patients developed minor complications with only 4% rate of minor bleeding.

CONCLUSIONS

Retrograde stone treatment using ureteroscopy and holmium laser lithotripsy can be safely performed in patients with bleeding diathesis with a low complication rate.

Percutaneous nephrolithotomy in patients on chronic anticoagulant/antiplatelet therapy

Percutaneous nephrolithotomy (PCNL) is an integral component in the management of large volume renal stone disease either as monotherapy or in combination with shock wave lithotripsy. Stone disease in patients on chronic anticoagulation/antiplatelet therapy, however, poses a difficult scenario. Bleeding is a major concern for any patient undergoing PCNL. We retrospectively analyzed our series of patients with renal calculi who were on chronic anticoagulant therapy and who underwent PCNL. We reviewed the case records of patients undergoing PCNL during the period from January 2005 to December 2011. We analyzed the changes in preoperative and postoperative hemoglobin, serum creatinine, and clotting parameters, as well as intraoperative and postoperative bleeding and thromboembolic complications. During the 5-year study period, a total of 36 patients (30 males and 6 females) with a mean age of 46.33±9.96 years (range, 29-61 years) who were on chronic anticoagulant/antiplatelet therapy underwent PCNL for urolithiasis. The mean size of the stone was 6.40±1.98 cm² (range, 2.8-9 cm²). The mean operating time was 62.08±10.10 min. The bleeding was successfully managed in all patients and the anticoagulant/antiplatelet agents were restarted after an appropriate duration. The mean rise in serum creatinine at discharge was 0.05±0.03 mg/dl and the mean fall in serum hemoglobin was 1.63±0.77 g/dl. At 3 months after surgery, the stone-free rate was 100%. With careful preoperative care and regulation of anticoagulation/antiplatelet therapy and appropriate intraoperative management, PCNL can be performed safely and successfully in properly selected patients with renal calculi who are on chronic anticoagulant/antiplatelet therapy.

A new scoring system for predicting stone-free rate after retrograde intrarenal surgery: the "resorlu-unsal stone score"

OBJECTIVE

To investigate the prognostic factors associated with the treatment efficacy of retrograde intrarenal surgery (RIRS) and develop a scoring system for predicting the stone-free rate after this surgery.

METHODS

We performed a retrospective analysis of 207 patients who underwent RIRS for renal stones between January 2009 and September 2011. Patient age, gender, body mass index, stone size, stone side, stone location, stone composition, number of stones, lower pole infundibulopelvic angle, using anticoagulant therapy, abnormal skeletal anatomy, and abnormal renal anatomy were investigated as potential preoperative predictive factors.

RESULTS

The present study included 111 (53.6%) men and 96 (46.4%) women. Mean patient age was 32.9 ± 18.8 years (range 1-74) and mean stone size was 16.2 ± 4.1 mm (range 8-40). Overall, 178 of the 207 (86%) patients were stone free after the initial treatment. Univariate analysis showed that stone size (P <.001), stone location (P = .025), stone composition (P = .01), stone number (P = .049), renal malformations (P = .042), and lower pole infundibulopelvic angle (P = .003) had significant influence on the stone-free rate after RIRS. Multivariate analysis excluded stone location from the logistic regression model, whereas other factors maintained their statistically significant effect on success rate, indicating that they were independent predictors.

CONCLUSION

Our study demonstrated that stone size, stone number, stone composition, infundibulopelvic angle, and renal malformations are significant predictors of RIRS outcome. A scoring system based on these factors helps separate patients into outcome groups and facilitates treatment planning.

Contemporary management of ureteral stones

CONTEXT

Ureteral calculi represent a common condition that urologists encounter in everyday practice. Several treatment options are available for calculi that do not pass spontaneously or are unlikely to do so.

OBJECTIVE

In this nonsystematic review, we summarize the existing data on contemporary management of ureteral stones focusing on medical expulsive therapy (MET) and different treatment modalities.

EVIDENCE ACQUISITION

A PubMed search was performed. We reviewed the recent literature on the management of ureteral calculi. Articles were considered between 1997 and 2011. Older studies were included selectively if historically relevant.

EVIDENCE SYNTHESIS

For stones that do not pass spontaneously or with MET, shock wave lithotripsy (SWL) and ureteroscopy (URS) are the most common and efficient treatment modalities. Both techniques have obvious advantages and disadvantages as well as different patterns of complications. For select cases or patients, other modalities may be useful.

CONCLUSIONS

Ureteral stones of up to 10mm and eligible for observation may be offered MET. For most ureteral calculi that require treatment, advances in SWL and URS allow urologists to take a minimally invasive approach. Other more invasive treatments are reserved for select "nonstandard" cases.

Safety of ESWL in elderly: evaluation of independent predictors and comorbidity on stone-free rate and complications

AIM

Urinary stone disease affects people of all ages. With its satisfactory efficacy ranges in all age groups and lack of side-effects, extracorporeal shock wave lithotripsy (ESWL) has become the preferred treatment modality for uncomplicated renal and proximal calculi ≤ 20 mm. In the present study, we aimed to assess the safety and efficacy of the ESWL treatment in elderly patients.

METHODS

A retrospective study was carried out on patients aged over 65 years who underwent shock wave lithotripsy at our Department from 2009 to 2011, with a Siemens Lithostar electromagnetic shockwave lithotripter. A total of 231 patients (157 males, 74 females) out of 1694 (13.6%) were studied. The patients were divided into two groups (group 1 = 65-70; group 2 >70). The effect of age and other possible predicting factors (sex, stone localization and stone size) were investigated. Concomitant diseases and related complications were also evaluated.

RESULTS

An overall stone-free rate (SFR) of 82.2% was found. The influence of sex on SFR was non-significant. There was no significant difference when comparing SFR between the age groups. When patients were divided into those with renal and ureteral stones, the SFR were 94.4% and 67.6% (P < 0.01), respectively. The SFR of the stone size groups, ≤ 10 mm and > 10 mm were 80% and 84.4%, respectively. Comorbidity was present in 148 patients. Complications were noted in 56 of 231 patients. Of 56 patients, 43 had minor complications and 13 major complications.

CONCLUSION

ESWL seems to be an effective first-line treatment choice for urinary stones in elderly patients with careful patient selection and personalized preparation.

Impact of Stone Size, Location, Composition, Impaction, and Hydronephrosis on the Efficacy of Holmium:YAG-Laser Ureterolithotripsy

OBJECTIVES

The impact and outcome of holmium:YAG-laser (Ho:YAG) ureterolithotripsy in treating proximal and distal ureteral stones was investigated.

METHODS

A total of 543 patients harbouring proximal (n=194) or distal (n=349) ureteral stones underwent semirigid Ho:YAG ureterolithotripsy. The degree of hydronephrosis; stone size, location, impaction, and composition; and complication and stone-free rates were recorded.

RESULTS

Mean stone size for proximal and distal stones was 7.1+/-3.6 mm and 6.2+/-2.5 mm, respectively. The stone-free rate on the first postoperative day was 79.4% for proximal and 96.8% for distal stones (p<0.0001). For proximal stones <10mm and > or =10mm, respectively, the stone-free rate was 80.5% and 74.3% (p=0.4) and for distal stones 97.3% and 94.3% (p=0.2). Stone-free rates for radio-opaque versus radiolucent stones in proximal stones were 79.6% versus 77.9% (p=0.8) and 97.6% versus 96.2% in distal stones (p=0.5). Impaction correlated significantly with stone-free rates (p<0.0001). Stone-free rates for nonimpacted versus impacted proximal stones were 85.8% versus 67.2% (p=0.003) and for distal stones 99.2% versus 91.4% (p<0.003), respectively. The presence or degree of hydronephrosis did not correlate with treatment success (p=0.4, p=0.8). The presence of intraoperative complications correlated significantly with proximal compared to distal ureteral stone location (p=0.004). Auxiliary measures in proximal versus distal stones were performed in 20.6% versus 2.9% (p<0.0001).

CONCLUSIONS

In this series, stone-free rates in Ho:YAG ureterolithotripsy were significantly higher in distal and nonimpacted stones but were independent of stone size and composition and the degree of hydronephrosis. Ureterolithotripsy in proximal stones was associated with higher intraoperative complication and retreatment rates compared to distal stones.