Comparison of mini-percutaneous nephrolithotomy and retroperitoneal laparoscopic ureterolithotomy for treatment of impacted proximal ureteral stones greater than 15 mm

Propensity score matched comparison of transperitoneal laparoscopic ureterolithotomy and percutaneous nephrolithotomy for management of large impacted proximal ureteral stones with long-term follow-up

Impacted proximal ureteral stones (IPUS) present challenging clinical scenarios due to their persistent nature and associated complications. While ureterorenoscopy (URS) lithotripsy is recommended as the primary treatment, controversies exist regarding the optimal management of such stones. In this retrospective analysis, we compared the operative outcomes and long-term results of transperitoneal laparoscopic ureterolithotomy (LU) and percutaneous nephrolithotomy (PCNL) for IPUS larger than 15 mm. Propensity score matching (PSM) was employed to mitigate potential selection biases. Following PSM, 83 patients in each cohort exhibited comparable baseline characteristics. LU demonstrated a superior surgical success rate (100% vs. 96.4%, p = 0.244) and significantly lower perioperative hemoglobin decline (0.6 ± 0.4 g/dL vs. 1.5 ± 0.7 g/dL, p = 0.036) compared to PCNL. Additionally, LU exhibited a higher stone-free rate after 2 months (100% vs. 91.6%, p = 0.043), but a longer duration of catheterization (7.4 ± 1.2 days vs. 3.5 ± 2.2 days vs., p = 0.011). Conversely, PCNL was associated with a higher incidence of total complications (21.7% vs. 9.6%, p = 0.033) and stone recurrence during a mean period of 40-month follow-up (20.5% vs. 8.4%, p = 0.027). Transperitoneal LU and PCNL represent effective interventions for managing IPUS exceeding 15 mm. Notably, LU emerges as a preferable option over PCNL, offering superior stone clearance rates, reduced perioperative complications, and lower recurrence rates.

Development of a radiomics model to discriminate ammonium urate stones from uric acid stones in vivo : A remedy for the diagnostic pitfall of dual-energy computed tomography

BACKGROUND

Dual-energy computed tomography (DECT) is purported to accurately distinguish uric acid stones from non-uric acid stones. However, whether DECT can accurately discriminate ammonium urate stones from uric acid stones remains unknown. Therefore, we aimed to explore whether they can be accurately identified by DECT and to develop a radiomics model to assist in distinguishing them.

METHODS

This research included two steps. For the first purpose to evaluate the accuracy of DECT in the diagnosis of uric acid stones, 178 urolithiasis patients who underwent preoperative DECT between September 2016 and December 2019 were enrolled. For model construction, 93, 40, and 109 eligible urolithiasis patients treated between February 2013 and October 2022 were assigned to the training, internal validation, and external validation sets, respectively. Radiomics features were extracted from non-contrast CT images, and the least absolute shrinkage and selection operator (LASSO) algorithm was used to develop a radiomics signature. Then, a radiomics model incorporating the radiomics signature and clinical predictors was constructed. The performance of the model (discrimination, calibration, and clinical usefulness) was evaluated.

RESULTS

When patients with ammonium urate stones were included in the analysis, the accuracy of DECT in the diagnosis of uric acid stones was significantly decreased. Sixty-two percent of ammonium urate stones were mistakenly diagnosed as uric acid stones by DECT. A radiomics model incorporating the radiomics signature, urine pH value, and urine white blood cell count was constructed. The model achieved good calibration and discrimination {area under the receiver operating characteristic curve (AUC; 95% confidence interval [CI]), 0.944 (0.899-0.989)}, which was internally and externally validated with AUCs of 0.895 (95% CI, 0.796-0.995) and 0.870 (95% CI, 0.769-0.972), respectively. Decision curve analysis revealed the clinical usefulness of the model.

CONCLUSIONS

DECT cannot accurately differentiate ammonium urate stones from uric acid stones. Our proposed radiomics model can serve as a complementary diagnostic tool for distinguishing them in vivo .

Percutaneous nephrolithotomy or flexible ureteral lithotripsy, which one is better for patients with upper ureteral calculi of 1.5-2.0 cm in diameter

PURPOSE

First research to evaluate the clinical efficacy and safety of flexible ureteral lithotripsy (FURSL) and percutaneous nephrolithotomy (PCNL) in the treatment of the upper ureteral stone is between 1.5 cm and 2.0 cm in diameter since there is no consensus with such ureteral stone yet.

METHODS

From December 2018 to October 2022, 104 patients with calculi in the upper ureter received percutaneous nephrolithotomy (PCNL)or flexible ureteroscopic lithotripsy (FURSL) in our institution. The clinical data of the patients in the two groups were retrospectively searched. Stone removal rate, operation time, blood loss, postoperative pain score, postoperative inflammatory factor, postoperative complication rates and ureteral obstruction three months after the operation were compared between the two groups.

RESULTS

A total of 104 patients were included in the study. The stone clearance rate and the secondary surgery rate were 88.89% and 7.41% in the FURSL group, the figures were 97.96% and 2.0% in the PCNL group (p = 0.067, 0.497). Regarding ureteral obstruction three months after the operation, there were 2 patients in FURSL group and 0 patients in PCNL group(p = 0.497).Compared to patients in FURSL group, patients in the PCNL group had shorter operation time(PCNL 71.81 ± 18.94 min vs. FURSL 86.80 ± 22.49 min, p = 0.0004), fewer complications(PCNL 20.37% vs. FURSL 6.12%), and lower postoperative inflammatory factor(p = 0.0004), yet they got more hemoglobin drop (PCNL 13.14 ± 9.81 g/L vs. FURSL 4.77 ± 3.55 g/L, p < 0.0001), higher postoperative pain scores(p = 0.0017) in the first three postoperative days and longer hospital stay (PCNL 4.96 ± 1.21 days vs. FURSL 3.60 ± 0.83 days).

CONCLUSION

Both FURSL and PCNL were effective methods for treating upper ureteral stones of 1.5-2.0 cm in diameter given the extremely high stone clearance rate and a very low secondary surgery rate, as long as rare ureteral obstruction in medium-long term observation. Additionally, FURSL can effectively reduce surgical bleeding, postoperative pain, and hospital stay, while PCNL can decrease operation time, the risk of infection, and complications. Therefore, doctors could select suitable surgical treatment for those patients depending on their different clinical situations based on these findings.

2022 Recommendations of The AFU Lithiasis Committee: Open surgery and laparoscopy

Only few hundred interventions are performed in France each year to remove upper urinary tract stones using a laparoscopic/robotic transperitoneal or retroperitoneal approach. These interventions are proposed to patients with large (>20mm) and complex stones, sometimes after failure of endoscopic techniques or in the presence of malformations that can be treated at the same time. The major interest of these interventions is the possibility to remove the whole stone without prior fragmentation. Some anatomical situations can increase the technical difficulty, particularly the presence of an intrarenal pelvis and the presence of pelvic and periureteral adhesions. The reported complications are essentially urinary fistula and ureteral stenosis, the risks of which are reduced by the use of double J stenting. As struvite stones are more friable, their whole removal is more difficult and may lead to dispersion of fragments, particularly during laparoscopy. Conventional open surgery has a higher stone-free rate, but comes with a greater kidney function loss. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU Guidelines on urolithiasis. 2022) and their adaptability to the French context.

Laparoscopic Ureterolithotomy and Single-Use Digital Flexible Ureteroscope For Unilateral Large Ureteral Stone and Small Renal Stone

BACKGROUND The removal of concurrent ureteral and renal stones within a single procedure has always been a challenge for urological surgeons. The incorporation of single-use digital flexible ureteroscopes into laparoscopic ureterolithotomy procedures has demonstrated effective removal of concurrent stones with a good clearance rate and decreased risk of bleeding and trauma. We report the successful removal of a unilateral upper ureteral stone and a smaller renal stone with this procedure. CASE REPORT A 60-year-old man visited the outpatient clinic with an ultrasonography report that revealed a large proximal ureteral stone with moderate hydronephrosis, accompanied by bilateral renal stones and prostatic hyperplasia. He had been experiencing urinary urgency for a year and was determined to undergo lithotomy. Due to his longstanding history of coronary artery disease and myocardial ischemia, the urologists decided that concurrent stone removal within an operation would be the best treatment. A preoperative computed tomography urogram measured the left ureteral and renal stones to be 2.0×0.8 cm and 0.6 cm, respectively. Both stones were successfully removed by laparoscopic ureterolithotomy using a single-use digital flexible ureteroscope. The patient had an uneventful recovery and remained well 1 month post-operation. CONCLUSIONS The application of single-use digital flexible ureteroscopes for laparoscopic ureterolithotomy has demonstrated safety, efficiency, and cost-effectiveness. The authors believe that it is a safe alternative for the removal of concurrent ureteral and renal stones, especially in patients with multiple comorbidities.

Analysis of the Mechanism of Ureproofing Technology and Postlaparoscopy on Patients with Urology and Infection

OBJECTIVE

To analyze the effect of ureteroscopy and retrolaparoscopy on urinary calculi and infection.

METHOD

A total of 64 patients with urinary calculi and infection who received treatment in our hospital from June 2018 to January 2018 were selected. According to the different treatment methods, they were divided into two groups: a control group and a study group. The study group was treated with laparoscopic ureteroscopy, and the control group was treated with ureteroscopy. The surgical results, complications, renal function, stress response, and inflammatory reaction were compared between the two groups.

RESULTS

Compared with the control group, the study group stone clearance rate was higher, the surgical time was shorter (P < 0.05); the incidence of complications in the study group (23.3%) was lower than that in the control group (5.9%) (P < 0.05); there was no significant difference in kidney function indicators before treatment (P > 0.05); after treatment, the SCR, BUN, NGAL, and Cys-C indicators of the two groups were significantly increased. Compared with the control group, the study group change was more obvious, and the difference was statistically significant (P < 0.05); after treatment, the two sets of stress response indicators were significantly increased, but relative to the control group, the study group stress response indicator was lower (P < 0.05); before treatment, there was no significant difference in inflammatory factors (P > 0.05); after treatment, the two sets of inflammatory factor levels were significantly increased, but relative to the control group, the study group was lower (P < 0.05).

CONCLUSION

In the clinical treatment of urinary stones, ureteroscopy technology and the laparoscopic technique have played an important role. But the laparoscopic technique is shorter, the stone clearance is higher, and the patient's renal function can be improved, and the patient is postoperative. The stress reaction should be small. Therefore, in the clinical treatment of urinary stones and infection, laparoscopic technical treatment is worth promoting.