Quality of Life after Percutaneous Nephrolithotomy for Caliceal Diverticulum and Secluded Lower-Pole Renal Stones

Decision regret analysis in early URSL vs medical expulsive therapy 1 for ureteric calculi ≤ 1cm

BACKGROUND

The study assesses the decisional regret following Shared Decision-making (SDM) in patients selecting either early ureteroscopic lithotripsy (URSL) or medical expulsive therapy (MET) for ureteric stones ≤ 1 cm, with the aim to evaluate their decisional Conflict, satisfaction, and regret regarding their opted treatment choices.

METHODS

Adults aged more than 18 years with one stone up to 1 cm in either ureter were included. After SDM, the patients were allocated into their opted group viz. URSL or MET. Patients in each group were reassessed at "treatment completion". Cambridge Ureteric Stone PROM (CUSP) questionnaire for HRQoL, Decision Regret Scale and the OPTION scale (SDM) were filled at treatment completion.

FINDINGS

111 patients opted for MET, while 396 patients opted for early URSL. Mean stone size was larger in URSL group (7.16 ± 1.63 mm vs. 5.50 ± 1.89; p < 0.001). Decisional conflict was higher in patients opting for URSL (77.3% vs. 57.7%; p < 0.001). Stone-free rate at four weeks was higher in URSL group (87.1%vs68.5%, p < 0.001). Decisional regret was higher in patients opting for MET (33.24 ± 30.89 vs. 17.26 ± 12.92; p = 0.002). Anxiety, was higher in patients opting for MET (6.94 ± 1.89 vs. 5.85 ± 1.54; p < 0.001). Urinary symptoms and interference in patients' travel plans and work-related activities were more in URSL group (6.21 ± 1.57 vs. 5.59 ± 1.46; p < 0.001 and 6.56 ± 1.59 vs. 6.05 ± 1.72; p < 0.001 respectively).

INTERPRETATION

After SDM, decisional regret is higher in patients opting for MET mainly due protracted treatment duration with increased pain and anxiety during the treatment course and the need for additional procedure for attaining stone clearance and the. Despite higher decisional conflict, a larger proportion of patients opt for early URSL with the aim of avoiding anxiety and achieving early stone clearance.

Efficacy of PCNL in the resolution of symptoms of nephrolithiasis

Patients undergo Percutaneous Nephrolithotomy (PCNL) for the resolution of pain, but at times, other symptoms such as hematuria, dysuria, nausea, emotional distress, and anxiety are also the presenting symptoms. While pain resolution after successful surgery is generally the focus, the resolution rate of other symptoms after surgery is not described. Our study aims to determine the efficacy of PCNL for the resolution of other symptoms. Patients aged > 18 years who underwent PCNL from September 2019 to 2021 were interviewed face-to-face and asked questions regarding their symptoms before and 3 months after the surgery. Their response was noted on an 11-point Numerical-Rating-Scale (NRS) of 0-10. The primary outcome was symptom resolution rate at 3 months after PCNL. The secondary outcomes were rate of resolution of gross hematuria, dysuria, anorexia and nausea, emotional distress and anxiety, work interference, and daily routine activities. Only patients who had complete stone clearance in a single sitting were included. Of the total 110 patients, almost half (45.45%) of the patients reported having one or more symptoms at or after 3 months of surgery. The reduction in proportion of patients and mean difference in preoperative and postoperative NRS scores of symptoms were statistically significant. Symptoms that persisted were mild and posed slight discomfort to the patient. Complete resolution of all the symptoms may not be achieved even in patients who have complete clearance after PCNL, and a few symptoms can persist, however, only mild. Appropriate preoperative counselling of the patients is, therefore, essential.

Decision-making and improvements in health-related quality of life in patients with kidney stones: comparing surgery versus observation using a mixed methods analysis

The experience of patients who choose observation or surgery for kidney stones has not been well established. We compared these patients using qualitative interviews, the Wisconsin Quality of Life questionnaire (WISQOL), and the Cambridge Renal Stone Patient Reported Outcome Measure (CReSP). Adult patients with upper tract urinary calculi for whom observation or intervention were options underwent qualitative interviews at baseline and at 2 months. WISQOL and CReSP were administered at baseline, and at 6–16 weeks post operatively if surgery was selected. Comparisons in patient experiences and quality of life measures were performed between groups. Among 15 patients who opted for surgery and 10 patients who opted for observation, we identified major themes in patient experiences related to context, health care episodes, patient responses, and perceived outcomes. A conceptual framework for the domains of patient experience during kidney stone disease was developed, which can be used by clinicians and patients to shape discussion. Baseline standardized WISQOL and CReSP scores were comparable between groups. In the surgery group, both WISQOL and CReSP scores improved after surgery (WISQOL 58 to 83, higher is better, p = 0.003; CReSP 31 to 23, lower is better, p = 0.009). Patients who underwent surgery for kidney stones reported improvements in quality of life after treatment via WISQOL and CReSP. A conceptual framework was developed for the patient experience of kidney stones which provides a common language for patients and clinicians.

The effect of shock wave lithotripsy and retrograde intrarenal surgery on health-related quality of life in 10-20 mm renal stones: a prospective randomized pilot study

The effects of treatment modalities such as retrograde intrarenal surgery (RIRS) and shock wave lithotripsy (SWL) on health-related quality of life (HRQoL) were determined in patients with renal stones between 10 and 20 mm. A total of 120 patients were included in the study and prospectively randomized to RIRS or SWL group. A total of 39 patients experienced treatment failure and finally 81 patients (45 patients in the RIRS group, 36 patients in the SWL group) were analyzed for HRQoL. SF-36 survey was used to determine HRQoL pre-operatively, post-operative day 1 and 1 month. The patient and stone characteristics such as age, gender, stone size, grade of hydronephrosis and body mass index were similar between the two groups. At post-operative day 1, the RIRS group was associated with lower scores of role functioning/physical (p = 0.008), role functioning/emotional (p = 0.047) energy/fatigue (p = 0.011), social functioning (p = 0.003) and pain (p = 0.003) when compared to the SWL group. At post-operative 1 month, only pain and emotional well-being scores (p = 0.012 and p = 0.011, respectively) in the RIRS group were statistically lower according to the SWL group. In our study, patients in the SWL group showed more favorable HRQoL scores when compared to the patients in the RIRS group in short-term follow-up.

Translation and Linguistic Validation of the Korean Version of the Wisconsin Stone Quality of Life Questionnaire

Purpose

Although cure rate and efficacy of treatment for urinary stone disease have been improved, clinicians have been indifferent to the quality of life (QoL) of stone patients in Korea. The objective of this study was to develop a Korean version of Wisconsin questionnaire about quality of life questionnaire (K-WISQOL) of stone patients for use in Korea.

Methods

Linguistic validation was permitted for translation by its developers. Three bilingual nonspecialists and 11 panels who were actively involved in treating urinary stone patients performed the translation and linguistic validations. A trained interviewer and 5 Korean patients carried out cognitive debriefing.

Results

Noun words such as “energy” and “responsibilities” were very difficult to translate to Korean. They were substituted by more comprehensive words. After backward translation, translated sentences showed a good agreement with the original WISQOL. During backward translation and the second reconciliation, previously translated Korean version was revised in 5 sentences. In the cognitive debriefing process, all 5 patients thought that these questions explained the patient’s situation well. Most of these respondents answered that explanatory notes of questionnaire were well written and the format of the questionnaire was easy to follow.

Conclusions

The present study demonstrated that, despite language differences, translation and linguistic validation of the K-WISQOL were successfully performed. This K-WISQOL could be useful tools for treatment plan and patient care.

A Randomized Controlled Comparison of Nephrostomy Drainage vs Ureteral Stent Following Percutaneous Nephrolithotomy Using the Wisconsin StoneQOL

OBJECTIVE

We compared postoperative outcomes and quality of life (QoL) between patients who received a nephrostomy tube vs a ureteral stent following percutaneous nephrolithotomy (PCNL) in a prospective, double-blind, randomized manner.

MATERIALS AND METHODS

Between September 2015 and March 2016, we randomized 30 patients undergoing PCNL to receive nephrostomy drainage (Group 1: 8F or 10F) or Double-J ureteral stent (Group 2) at conclusion of surgery. Nephrostomy tubes were removed within 48 hours (before discharge) and ureteral stents were removed at least 2 weeks after surgery. Patients' QoL was assessed with the Wisconsin StoneQOL questionnaire preoperatively and then 7 to 10 days and 30 days following surgery. Inclusion criteria included an uncomplicated procedure, normal preoperative renal function, and clinically insignificant residual stone fragments on postoperative imaging. We calculated the preoperative and postoperative QoL score difference between the two groups. We also evaluated perioperative characteristics, inpatient analgesic requirements, length of stay (LOS), and postsurgical complications.

OUTCOME

Patient characteristics between Groups 1 and 2 were comparable with similar age (58.3 vs 54.7, p = 0.534), gender ratio, and stone burden (276.6 mm² vs 259 mm², p = 0.84) and composition. There was no significant difference between perioperative outcomes, including stone-free rate (93.3% vs 86.7%), operative times (125.7 minutes vs 115 minutes, p = 0.29), estimated blood loss (103.3 mL vs 100.7 mL, p = 0.9), LOS (3.2 days vs 1.9 days, p = 0.1), and complications (2 in each group). Inpatient analgesic requirements were also the same (both 21.1 mg, p = 1.0). Assessment of QoL using the Wisconsin StoneQOL questionnaire showed significant differences between preoperative and postoperative health-related QoL in 18 of the 28-question instrument at 7 to 10 days. Patients in Group 2 had significantly worse QoL change and a multitude of negative responses on the StoneQOL assessment, not only those commonly associated with stent irritation. Eighty percent of participants in Group 2 also attributed their complaints to having a stent placed. Both groups had similar QoL status at 30 days after surgery.

CONCLUSION

Despite the literature advocating "tubeless" PCNL with ureteral stent placement at conclusion of surgery, our randomized prospective study shows that QoL is significantly worse with stent placement than with temporary nephrostomy drainage in the immediate aftermath following PCNL, using a validated QoL assessment instrument specific for nephrolithiasis.

Percutaneous nephrolithotomy for 1-2 cm lower-pole renal calculi

Objectives:

The most appropriate management of patients with lower-pole calyceal (LC) stones remains controversial. In this review we discuss the role of percutaneous nephrolithotomy (PCNL) in the management of LC stones 1–2 cm in maximum dimension.

Materials and Methods:

A detailed literature review was performed to summarize the recent technical developments and controversies in PCNL. The results of PCNL for 1-2 cm LC calculi were reviewed.

Results:

PCNL is increasingly employed as a primary modality in the treatment of LC calculi. It has a high success rate and acceptably low percentage of major complications in experienced hands. Supine position is found to be as safe and effective as prone position. Urologist-acquired access is associated with fewer access-related complications and better stone-free rates. Ultrasound is increasingly employed as an imaging modality for obtaining access. There have been increasing reports of tubeless PCNL in the literature. Most patients undergoing tubeless PCNL do not need hemostatic agents as an adjuvant for hemostasis. Non-contrast computed tomography does not yield statistically valuable increase in the diagnosis of significant residual stones compared with that of plain X-ray and linear tomography. Comprehensive metabolic evaluation and aggressive medical management can control new stone recurrences and growth of residual fragments following PCNL.

Conclusions:

PCNL is a highly effective procedure with consistently high stone-free rates when compared with extracorporeal shockwave lithotripsy or retrograde intrarenal surgery. The results also do not depend on anatomic factors and stone size. It is associated with low morbidity in experienced hands.

Management options for lower pole renal calculi

PURPOSE OF REVIEW

The optimal treatment of lower pole renal calculi is controversial. Shock wave lithotripsy, ureteroscopy and percutaneous nephrostolithotomy all constitute viable therapeutic options in select patients.

RECENT FINDINGS

Lower pole stones smaller than 1 cm in diameter can be managed with observation, shock wave lithotripsy or ureteroscopy. Patients electing expectant management should be counseled regarding the potential for stone-related symptom progression and need for future intervention. Shock wave lithotripsy and ureteroscopy have similar stone-free rates, although shock wave lithotripsy may be preferable due to more favorable secondary outcomes. Lower pole stones 1-2 cm in diameter are best managed with percutaneous nephrostolithotomy, although ureteroscopy is an option in select patients, particularly those not considered candidates for percutaneous nephrostolithotomy. Finally, patients with lower pole stones larger than 2 cm are best served with percutaneous nephrostolithotomy, as the morbidity in experienced hands is low and stone-free rates are unequivocally higher than those of other treatment modalities.

SUMMARY

A variety of factors, including patient body habitus, local renal anatomy, cost and patient preference, must be taken into consideration when determining the optimal treatment modality for lower pole renal calculi.