A Novel Decision Aid to Support Informed Decision-Making Process in Patients with a Symptomatic Nonlower Pole Renal Stone <20 mm in Diameter

Patient's preferences: an unmet need by current urolithiasis guidelines: a systematic review

INTRODUCTION

Shared decision making (SDM) in surgical specialties was demonstrated to diminish decisional regret, decisional anxiety and decisional conflict. Urolithiasis guidelines do not explicit patient preference to choose treatment. The aim of this review article was to perform a systematic evaluation of published evidence regarding SDM in urinary stone treatment.

METHODS

A systematic review in accordance PRISMA checklist was conducted using the MEDLINE (PubMed) database. Inclusion criteria were studies that evaluated stone treatment preferences. Reviews, editorials, case reports and video abstracts were excluded. ROBUST checklist was used to assess quality of the studies.

RESULTS

188 articles were obtained. After applying the predefined selection criteria, seven articles were included for final analysis. Six out of seven studies were questionnaires that propose clinical scenarios and treatment alternatives. The last study was a patient preference trial. A general trend among included studies showed a patient preference towards the least invasive option (SWL over URS). The main reasons to choose one treatment over the other were stone-free rates, risk of complications and invasiveness.

DISCUSSION

This review provides an overview of the patients' preferences towards stone treatment in small- and medium-sized stones. There was a clear preference towards the least invasive management strategy. The main reason was less invasiveness. This is opposed to the global trends of performing more ureteroscopies and less SWL. Physicians played a pivotal role in counselling patients. SDM should be encouraged and improved. The main limitation of this study is the characteristics of the included studies.

Patient compliance for metabolic evaluation and medical treatment (CoMET) in calcium-oxalate stone patients: prospective study by EULIS eCORE study group

PURPOSE

In this study, we aimed to identify the compliance rates of calcium-oxalate stone patients for metabolic evaluation, diet and medical treatment and also determine the factors that are associated with poor compliance rates.

METHODS

This study was conducted by the EULIS eCORE working group prospectively. In the initial visit, demographic and stone-related characteristics were recorded. Patients were suggested metabolic evaluation, dietary advices and medical treatment. Follow-up visit was performed after 3 months and compliance rates were recorded. Logistic regression analysis was performed to determine factors associated with poor compliance to metabolic evaluation, diet and medical treatment.

RESULTS

Data of 346 patients from nine centers were analyzed. Compliance rates were 71.7%, 65.3%, and 63.7% for metabolic evaluation, diet, and medical treatment, respectively. In multivariate analysis, level of education (p = 0.003), history of emergency department visit (p = 0.04), number of stone surgeries (p = 0.03), patient care in dedicated stone clinic (p = 0.03), and history of shock wave lithotripsy (p = 0.005) were detected as independent predictors of compliance to metabolic analysis. Level of education (p < 0.001) and history of emergency department visit (p = 0.01) were detected as independent predictors of patient compliance to diet. Number of stone episodes (p = 0.03), family history of stones (p = 0.02), and polypharmacy (p < 0.001) were detected as independent predictors of patient compliance to medical treatment.

CONCLUSIONS

Patient compliance to metabolic evaluation, diet, and medical therapy is important for successful management of urolithiasis. Dietary advices and medications should be personalized by taking in to account the factors associated with poor compliance.

Flexible ureteroscopy versus miniaturized percutaneous nephrolithotomy for renal stones of 1-2 cm

Technological advances and innovation in endourology have significantly reduced the indications of extracorporeal shockwave lithotripsy in the management of moderate-sized renal stones. In the last decade, we have witnessed a trend towards the use of finer scopes for percutaneous procedures instead of standard percutaneous nephrolithotomy (PCNL) (≥22 Fr). Miniaturized PCNL (mPCNL), i.e. miniPCNL (12–20 Fr), ultra-miniPCNL (11–13 Fr), mini-microPCNL (8 Fr), and microPCNL (<5 Fr), is increasingly being used. Concomitant developments in laser technology have provided a safe and effective stone fragmentation modality for use via flexible ureteroscopes (fURS). Technological advances in the design of fURS have improved not only the optics (fiber optic to chip-on-the-tip technology digital image) but also the ergonomics. Both the endourological techniques are extremely effective and safe, as shown in a multitude of good-quality studies. There are some differences in stone-free rate and complications. mPCNL in general has a higher stone-free rate, albeit with a slightly higher incidence of hemorrhagic complications. fURS often requires longer stenting time and longer period to achieve stone clearance, whereas mPCNL often needs ureteral catheter for only 24 hours and has a higher first day stone-free rate. fURS is a 1 day procedure compared to mPCNL, which requires patients to stay hospitalized for 2–3 days. It is therefore important to tailor the indications of these two procedures to the individual patient’s needs.

The role of a novel decision aid to support informed decision making process in patients with a symptomatic non - lower pole renal stone < 20 mm in diameter: a prospective randomized study

Objectives

To evaluate the efficacy of a novel decision aid (DA) in improving the patients’ level of knowledge and decreasing decisional conflicts while deciding for SWL vs. RIRS in case of a symptomatic renal stone <2 cm.

Materials and Methods

In this prospective randomized study patients were randomized to receive either standard informing process (group 1, n=57) or DA (group 2, n=58). Level of knowledge was assessed with a questionnaire of 10 questions before and after patient informing process. Level of decisional conflict was assessed with a previously validated scoring system. Logistic regression analysis was performed to identify factors associated with adequate level of knowledge.

Results

Level of knowledge increased significantly in both groups after patient informing process. The increase was significantly more prominent in group 2 (p=0.045). Percentage of patients with adequate knowledge was also higher in group 2 (56.1%vs.74.1%, p=0.04). Mean decisional conflict scale score (higher score indicates higher decisional conflict level) was also significantly higher in group1 (14.7±14.5 vs. 10.1±13.7, p=0.045). Multivariate logistic regression analysis revealed higher education level (college degree) and use of DA as factors associated with adequate level of knowledge.

Conclusions

In the current study, The DA was shown to have a positive impact on level of knowledge and diminish the level of decisional conflict for patients with a symptomatic non-lower pole renal stone <20 mm. We recommend development and use of DAs for particular clinic scenarios to aid in education of patients and shared decision making process in stone disease clinics.