Evolution of stone management in Australia

Sudden cardiovascular collapse during the TUL procedure: A case series

Although ureteroscopy is a minimally invasive procedure, there have been reports of some minor and major complications, from self-limited to complicated events such as ureteral avulsion, urosepsis, and even death due to cerebrovascular accidents and deep vein thrombosis. Herein, we aim to report seven patients who presented with cardiovascular collapse during ureteroscopy in a 19-year period from January 2002 to January 2021.

Ureterorenoscopic stone procedures have low success rates and poor post-operative follow-up: results from an Australian tertiary health service

BACKGROUND

To assess the results of ureterorenoscopy (URS) for upper tract urolithiasis in a contemporary Australian tertiary healthcare setting.

METHODS

Hospital records of all URS stone procedures performed between January 2017 and December 2018 in a metropolitan service were retrospectively reviewed. Outcome measures including stone free rates, adherence to postoperative follow-up and complications rates were recorded.

RESULTS

385 patients (387 renal units) with mean age 53.8 (range 18-89) underwent URS for stones measuring between 2 and 27 mm (median 8 mm). 465 URS were performed with 1029 total procedures performed. 48.6% of operations were performed as day cases. Complications were recorded in 9% of the 465 URS cases with 42.9% of these Clavien II or more. The representation rate to our Emergency Departments was 15.4%. Only 49.1% (201) of patients had a follow-up review with imaging to assess stone free rates. Of the 201 patients who underwent imaging, only 38.3% were stone free. Stone analysis was performed in 34.5%.

CONCLUSION

Less than half of all patients were reviewed despite undergoing expensive, time consuming surgery for a condition with a high recurrence rate. In agreement with recent publications stone-free rates were low, with significant complications and representation rates. Stone surgery should be given the attention and resources equivalent to cancer surgery to improve results.

LEVEL OF EVIDENCE

2b.

Radiation exposure in emergency ureteric stenting: A subgroup analysis by operator

Objectives

To review radiation exposure during emergency ureteric stent insertion to identify differences based on operator experience, specialty operator and stone characteristics.

Patients and methods

A retrospective audit over 10 years was performed for patients who underwent emergency stent insertion for urolithiasis with intraoperative fluoroscopy. Outcomes measured included operator experience, radiation exposure (mGy), dose area product (Gy/cm2), fluoroscopy time, stone characteristics and patient BMI. Analysis was performed in IBM SPSS Version 28. p < 0.05 was considered statistically significant.

Results

Four hundred ten patients were identified, with a median age of 57 years, 64.6% male and a median BMI of 30. Urolithiasis was left-sided in 50.8%, with a median size of 7 mm and predominantly proximal (49%) followed by mid (34.5%) and distal (12.1%) location. Median radiation exposure was 12.6 mGy, 2.94 Gy/cm2 and fluoroscopy time 44.5 s, with no significant difference between consultants and registrars. No significant association between radiation exposure for subgroups of stone location, gender, size, laterality or specialty registrar (general surgery vs. urology).

Conclusion

No significant difference in radiation exposure was identified between registrars and consultants or between subspecialty registrars. We suggest formal radiation safety education for all health professionals involved with intra-operative fluoroscopy and personal dosimeters.

Residual fragment size following retrograde intrarenal surgery: a critical evaluation of related variables

Given the limited data on the predictive factors of residual kidney stone size after flexible ureteroscopy (fURS), this study aims to investigate the variables affecting residual stone size. The medical records of 642 patients without complications being treated for kidney stones with fURS between July 2014 and May 2022 were reviewed retrospectively, and the information of the 170 patients in whom residual stones were found was recorded. In addition to patient-specific factors and stone characteristics, length of postoperative hospital stay, postoperative fever, and preoperative antiaggregant use were evaluated. Of the 170 patients ultimately included in the study. The mean age was 51.56 (± 14.70). The mean stone size was 14.01 mm (± 5.75), the mean residual stone size was 7.04 mm (± 2.51), and the mean stone density was 829 Hounsfield units (± 395.06). The mean infundibulopelvic angle (IPA) was 49.37º (± 15.37), and 41.2% of the stones were non-opaque. The mean parenchymal thickness was 22.88 mm (± 5.55). 34 patients were on antiaggregant therapy. Preoperative stone size increases in stone density and decreases in IPA were found to be correlated with increase residual stone size (p < 0.001, p < 0.001, and p < 0.001, respectively). In addition, larger residual stones were observed after the fURS procedure in patients using anticoagulants and those without hydronephrosis (p = 0.02 and p = 0.016, respectively). Use of reliable predictive factors to forecast residual stone size after fURS may help to inform those treated and enable urologists to design rational surgical strategies.

A 15-year longitudinal analysis of the trends in the surgical management of renal and ureteric stones in Australia

Objective:

This study evaluates the evolving surgical management of renal stones in Australia over the past 15 years.

Methods:

The National Australian Medicare and Australian Institute of Health and Welfare (AIWH) data were used to obtain the annual number of hospital presentations for urolithiasis and surgical procedures for upper urinary tract stones from 2005 to 2020. The four treatment modalities observed included nephrolithotomy, shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL) and endoscopic lithotripsy.

Results:

The total number of renal colic presentations in Australian hospitals and urology procedures claimed by Medicare has increased during the past 15 years. A total of 218,999 urological procedures were claimed by Medicare for renal stones over 15 years. There has been a dramatic rise in endoscopic lithotripsy surgery for stones. In 2005–2006, endoscopic lithotripsy comprised 56.6% of total stonework claimed by Medicare, and this proportion jumped to 88.9% in 2019–2020. All other modalities saw a decline in absolute and relative numbers.

Conclusion:

Endoscopic management of upper renal tract stones predominates in the current management of renal stone disease in Australia. Epidemiology audits such as this study can provide insight into national disease trends and guide future healthcare policies and resource planning.

Level of evidence:

2b

Changing Trends in Surgical Management of Nephrolithiasis among Young Adults: A 15-Year Population-Based Study

Background: Increases in obesity and diabetes rates among all ages have led to a greater prevalence of nephrolithiasis worldwide. We aimed to explore the changing trends in surgical management of nephrolithiasis in young adults over a 15 year period. Methods: We reviewed medical records of military personnel for information on the diagnosis and care of nephrolithiasis before and during active service between 2007−2021, divided into three 5 year periods: 2007−2011, 2012−2016, and 2017−2021. Demographic, clinical, radiological, and surgical data were retrieved for the analysis of changing trends. Results: The records of 1,117,692 recruits yielded 7383 (0.66%) with stone-related surgeries, of whom 1885 were operated during military service. Their median age was 19.6 years (interquartile range [IQR] 16.8−21.2), 829 (70%) were males, and the cohort’s median body mass index was 23.6 (IQR 17.3−26.1). There was a dramatic decline in shock wave lithotripsy (SWL) prevalence (35.1%, 10.4%, and 4.4%, respectively) with a continually increasing prevalence of ureteroscopy (URS)/retrograde intrarenal surgery (RIRS) (62.7%, 88.5%, and 94.6%, p = 0.01). Percutaneous nephrolithotomy (PCNL) procedures have become nearly extinct over time (0.8% in 2017−2021). The number of median-sized stones treated by URS/RIRS increased (7.5 mm, 8.2 mm, and 9.7 mm, p = 0.044), but not those treated by SWL/PCNL. The median length of medical leave for URS/RIRS and PCNL decreased significantly (7 vs. 4 days, p = 0.05 and 10 vs. 6 days, p = 0.036, respectively), with no comparable change for SWL. There was a substantial decline in ancillary procedures in the URS/RIRS groups (9%, 6.8%, and 3.1%, p < 0.01), but not in the SWL/PCNL groups. Conclusions: Advancements in technology and surgical training are leading to the extinction of SWL and the adoption of URS/RIRS as the new standard of care for nephrolithiasis among young adults.

Contemporary treatment trends for upper urinary tract stones in a total population analysis in Germany from 2006 to 2019: will shock wave lithotripsy become extinct?

PURPOSE

To describe the change in upper urinary tract stone management in Germany over a 14-year period.

METHODS

Using remote data processing we analyzed the nationwide German billing data from 2006 to 2019. To analyze the clinics' case numbers and regional trends, we used the reimbursement.INFO tool based on standardized quality reports of all German hospitals. To also cover shock wave lithotripsy (SWL) as an outpatient procedure, we analyzed the research database of the Institute for Applied Health Research with a representative anonymous sample of 4 million insured persons.

RESULTS

The number of inpatient interventional therapies for upper tract urolithiasis in Germany increased from 70,099 cases in 2006 to 94,815 cases in 2019 (trend p < 0.0001). In-hospital SWL declined from 41,687 cases in 2006 to 10,724 cases in 2019 (decline of 74%; trend p < 0.0001). The percentage of SWL as an outpatient procedure increased between 2013 and 2018 from 36 to 46% of all performed SWL, while total SWL case numbers declined. Contrarily, the number of ureteroscopies increased from 32,203 cases in 2006 to 78,125 cases in 2019 (increase of 143%; trend p < 0.0001). The number of percutaneous nephrolithotomy also increased from 1673 cases in 2006 to 8937 in 2019 (increase of 434%; trend p < 0.0001).

CONCLUSION

We observed an increase in interventional therapy for upper tract urolithiasis in Germany with a dramatic shift from SWL to endoscopic/percutaneous treatment. These changes may be attributed to enormous technological advances of the endoscopic armamentarium and to reimbursement issues.

Endoscopic Ureteral Dilation Balloon Catheter for a Difficult Ureter: A New Novel Approach

OBJECTIVES

This study aims to assess the safety and efficacy of INNOVEXTM ureteral dilation balloon catheter to promote the likelihood of passing the ureter to complete primary ureteroscopy (URS).

METHODS

This was a prospective case series of patients during URS between August 2018 and January 2020 at the Pudong New District People's Hospital. A 12-Fr INNOVEXTM ureteral dilation balloon catheter was used to dilate the ureter when a 5° Wolf 6.0/7.5-Fr ureteroscope encounters an unpredictable hindrance to retrograde access for ureteral stones. Patients with documented ureteral strictures, radiation therapy, or urothelial cancer were excluded from the analysis. The primary outcomes were to characterize the use, safety, and efficacy of ureteral dilation balloon catheter to promote stone treatment during URS.

RESULTS

Eight hundred and sixty-two patients underwent primary URS of ureteral stones over the study period. The use of a ureteral dilation balloon catheter to promote ureteral access was performed in 65 (7.54%) cases and effectively allowed completion of the procedure in 58 (89.23%) cases. No ureteral perforation and access loss occurred during the operation. Seven patients required ureteral stent placement for passive ureteral dilation, with definitive stone treatment later. Postoperative radiographic follow-up was available for 63 (96.92%) cases, and no ureteral stenosis was observed after balloon dilation.

CONCLUSION

The use of a new ureteral dilation balloon catheter before endoscopic treatment of ureteral stones was associated with a high success rate and few complications. The convenient use method under direct vision at the whole process may increase the willingness of doctors to use it. In addition, it may reduce the need for secondary procedures for patients undergoing URS to manage ureteral stones.

Retrospective epidemiological study of urolithiasis in western Algeria over a period of 50 years

Background

Urolithiasis is a pathology that changes with time and with the evolution of human societies. The prevalence of this pathology has gradually increased during the last decades, especially because of dietary changes.

Methods

This work is a retrospective descriptive epidemiological study of the temporal type carried out at the level of the urology service of the University Hospital Center of Oran between the first January 1965 and December 31, 2014. The objectives of this work are to study the epidemiological profile of urolithiasis and to determine the evolutionary trend of the disease over time.

Results

This study confirms some current data in the direction of an increase in surgical activity concerning the treatment of urinary stones. The analysis over time shows us a significant decrease (p < 0.01) in the male predominance between 1965 and 2014 with a M/F ratio which decreased from 3.09 to 1.82, as well as an increase in the average age, rising from 28.8 years in the period 1965–1974 to 48.3 years between 2005 and 2014.

Conclusion

The analysis of epidemiological data is essential to better evaluate the evolution of the urolithiasis disease, which was affirmed in our study, where a constant evolution of the characteristics of the disease was revealed, testifying the change of the socio-economic level in Algeria.

Predictive factors of postoperative septic complications after flexible ureteroscopy for urinary stones

BACKGROUND

Flexible ureteroscopy (fURS) is one of the recommended treatments for urinary stones. Urosepsis is one of the most frequent complications of fURS however its predictive factors remain uncertain. Our objective was to assess the septic complications rates of fURS and to determinate predictive factors of these complications in patients undergoing fURS.

METHODS

Our retrospective analysis included all patients admitted for any fURS for stone disease in our center from December 2009 to April 2013. Patients' medical history, urine culture, stone composition, surgical and anesthetic characteristics were collected. The primary endpoint was defined by the presence of any septic complication (i.e. postoperative fever, urosepsis, septic shock or death). We used multivariate logistic regression to assess predictive factors of septic complication related to fURS.

RESULTS

Two hundred and eighty-two patients were included in this study. Urosepsis rate was 9.8% while 18.9% developed postoperative hyperthermia (>37.5°C). In multivariate analysis, the predictive risk factors of septic complication were: a neurologic disorder (OR=6.1; CI95%: 2.9-17.1), a history of urinary tract infection (UTI) (OR=19.6; CI95%: 7.3-52.1), exposure to peroperative nitrous oxide (OR=3.2; CI95%: 1.5-6.8) and intraoperative use of a laser (OR=8.0; CI95%: 13.0-30.3).

CONCLUSION

The use of fURS is associated with relatively frequent septic complications. Patients with neurologic disorders or a history of UTI carry an increased risk of postoperative complications. Limitations should be drawn with the use of peroperative nitrous oxide. These results should be further validated.

LEVEL OF EVIDENCE

3. Retrospective cohort study.

Efficacy of tamsulosin versus tadalafil as medical expulsive therapy on stone expulsion in patients with distal ureteral stones: A randomized double-blind clinical trial

Purpose:

To compare the effects of tadalafil, tamsulosin, and placebo as a medical expulsive therapy (MET) for distal ureteral calculi.

Materials and Methods:

This prospective randomized double-blind clinical trial was conducted on 132 renal colic patients with distal ureteric stones (≤10mm) over a period of 12 months. Patients were randomly divided into three groups. Patients in group A received tamsulosin 0.4mg, in group B received tadalafil 10mg, and in group C received placebo. Therapy was given for a maximum of 4 weeks. The rate of stone expulsion, duration of stone expulsion, the dose and the duration of nonsteroidal anti-inflammatory drugs (NSAIDs), analgesic use, and adverse effects of drugs were recorded.

Results:

Demographic profiles were comparable between the 3 groups. Although the stone expulsion rate in group A (72.7%) was higher in comparison to group B(63.6%) and group C(56.8%), it was not considered statistically significant (P=0.294). Shorter mean time to stone expulsion was significantly observed in group A (17.75±75), than group B(21.13±1.17) and group C(22.25±1.18) (P=0.47). The mean number of analgesic use was 9.8±5.09 days in group A, 14.6±7.9 days in group B, and 12.6±22.25 days in group C, this difference was significant (P=0.004). The analgesic requirement (doses of NSAIDs and pethidine) in group A was significantly lower than other groups (P<0.05). Also, patients in group A reported fewer headaches compared to other groups (P=0.011).

Conclusion:

Tamsulosin as medical expulsive therapy is more effective for distal ureteric stones with less need for analgesics and less stone expulsion time than tadalafil.

Predictors of success following extracorporeal shock-wave lithotripsy in a contemporary cohort

OBJECTIVES

The objectives of this study are to determine the predictors of success following extracorporeal shock-wave lithotripsy (ESWL) in a contemporary cohort at a high-volume stone center.

METHODS

We conducted a retrospective review all patients who underwent an elective ESWL within our institution over a 24-month period (January 2014 to December 2015). Data on patient demographics, stone variables, and inpatient treatment outcomes were evaluated.The presence of residual stone fragments larger than 4 mm on follow-up imaging was considered to be treatment failure. Using this threshold, clinically relevant variables between the treatment success and failure groups were identified. Multivariable logistic regression analyses (MVA) of clinically relevant variables were used to determine the independent factors predicting ESWL success.

RESULTS

Of 446 study eligible patients, 421 patients had complete follow-up data and were included in the analysis. Treatment was successful in 72.2% of patients in this study. Stone size, number of shocks delivered, and maximum treatment intensity were statistically different in the two groups. In a MVA where stone size, location, density, presence of ureteric stent, skin-stone distance (SSD), number of shocks, and maximum shock intensity were included, only stone size of <10 mm (odds ratio [OR] 3.4 [95% confidence interval [CI]: 1.98-5.84]) and SSD <15 cm (OR: 0.133, [95% CI: 0.027-0.65]) were the independent predictor of ESWL success.

CONCLUSION

We have demonstrated "real world" outcomes with high-volume use of ESWL. In our experience that with diligent patient selection, ESWL remains an effective tool for the management of upper tract calculi.

Does extracorporeal shock wave lithotripsy before retrograde intrarenal surgery complicates the surgery for upper ureter stone? The results of the RIRSearch group

AIMS

To evaluate the effect of pre-RIRS ESWL on the efficiency and safety of RIRS in the treatment of proximal ureter stones.

METHODS

The patients in the study population were divided into two groups. Group-1 was composed of patients who had undergone ESWL for proximal ureter stones before RIRS and Group-2 was composed of patients who directly underwent RIRS without any prior ESWL. The clinical and demographic properties of the patients were analysed in the RIRSearch database. The operative outcomes, peroperative complications, postoperative complications, hospitalisation time and stone-free rates were compared between the groups.

RESULTS

There were 56 patients in Group 1 and 95 patients in Group 2. The demographic and clinical properties were similar between the groups. The stone-free rates, peroperative complications and postoperative complications were also similar between the groups; however, the fluoroscopy time was significantly higher in Group 1 (P = .043). The cut-off duration of 10 weeks between ESWL and RIRS had reasonable/favourable discriminating ability, with a 51% sensitivity and 88% specificity rate for stone-free status.

CONCLUSION

Performing ESWL on the proximal ureter stones before RIRS did not change the efficacy and safety of RIRS. The time between the patient's last ESWL session and RIRS had a predictive value for stone-free status, but did not have any effect on complications.

Shifted Firefighter Health Investigation by Personal Health Insurance Record in Taiwan

INTRODUCTION

Taiwan's firefighters use a shift rotation system with 2 days of work and 1 day of rest. Numerous papers have already explored the risks of shift work to the body. However, little data concern the impact of shift work on health as reflected in medical visits. This study used individuals' medical visit record in Taiwan's health insurance system. The locally called "health bank" contains individuals' medical visit record, health insurance payment points and the medicine used.

METHODS

Consent was obtained from 150 firefighters who were serving under the shift rotation system to obtain their 2015 individual "My Health Bank" medical data. Comparisons were made between national health insurance data norm.

RESULTS

Firefighters make significantly more visits for Western medicine than the annual average (firefighters 6.27 vs norm 5.24, P = 0.04142), more total number of medical visits (9.57 vs 7.75, P = 0.0102), more annual average payment points for Western medicine (4079 vs 2741, P = 0.003151), and a greater average number of total annual medical visit points (7003 vs 4940, p = 0.0003157). Firefighters had significantly higher incidents of respiratory diseases, urogenital diseases, skin and subcutaneous tissue diseases, musculoskeletal system and connective tissue diseases, injuries, and illness from poisoning than did the norm (P<0.05).

CONCLUSION

A persuasive health-survey-based method for workers in high occupational hazard industries was proposed in this study, and the result was highly correlated with risk factors of fireworkers. The proposed study method is potential to investigate risk factors of other working.

Current scenario of endourological treatment of kidney stones in brazil: results of a national survey

Objective:

To elucidate the current scenario of endourology in Brazil for the treatment of urinary lithiasis, with an emphasis on regional differences and the reasons why certain techniques are still underutilized.

Materials and Methods:

An electronic questionnaire was sent by email to the 4,745 members of the Brazilian Urological Society (BSU) in 2016 to collect information on the 3 main endourological procedures used in the treatment of nephrolithiasis: Semi-rigid ureteroscopy (URS), Flexible ureteroscopy (F-URS) and percutaneous nephrolithotripsy (PCNL).

Results:

A total of 1,267 urologists answered the questionnaire. It was observed that the vast majority perform URS (95.6%), while 80.2% perform F-URS and only 72.1% perform PCNL. Regarding the surgical volume, most perform up to 10 procedures per month (73.4% to 88.2%) and the main impediment was the lack of patients with the pathology (42.1% to 67.7%). The lack of equipment or hospital infrastructure was one of the main limiting factors for rigid (23%) and flexible (38.1%) URS, mainly in the North and Northeast regions of the country. Regarding PCNL, most of them reported lack of practical experience in the method (29.9%). Finally, most urologists expressed interest in taking courses in endourology.

Conclusion:

Ureteroscopy, rigid or flexible, is already well established in the country, requiring the direction of more resources for its practice, especially in less developed regions. Regarding PCNL a significant part of Brazilian urologists still lack practical experience in this procedure, emphasizing the need for greater investment in teaching this technique.

Single-use disposable digital flexible ureteroscopes: an ex vivo assessment and cost analysis

OBJECTIVE

To assess and measure the capability of a single-use disposable digital flexible ureteroscope, the LithoVue™ (Boston Scientific, Marlborough, MA, USA), and to assess if there is a benefit to switching to single-use scopes.

PATIENTS AND METHODS

The LithoVue was compared to two commonly used reusable flexible ureteroscopes (Olympus URF-V [Olympus, Tokyo, Japan] and Karl Storz Flex-X^c [Karl Storz & Co. KG, Tuttlingen, Germany]) ex vivo. An analysis of reusable ureteroscope usage was performed to evaluate damage, durability, and maintenance costs. This was then compared to the projected costs of using single-use disposable scopes.

RESULTS

Flexion, deflection and irrigation flow of the LithoVue was equivalent, if not better than the reusable flexible ureteroscopes. An analysis of 234 procedures with seven new Olympus URF-V scopes, revealed 15 scope damages. Staghorn stones and lower pole/mid-zone stones were significant risk factors for damage (P = 0.014). Once damage occurred it was likely to occur again. Total repair costs were $162 628 (Australian dollars) (£92 411 in Great British pounds), the mean cost per case was $695 (£395). Factoring in the purchase cost, cleaning and repair costs, the cumulative cost of 28 reusable flexible ureteroscopy procedures was ~$50 000 (£28 412). If the LithoVue was priced at $1 200 (£682), switching to a single-use scope would cost ~$35 000 (£19 888).

CONCLUSION

The LithoVue is analogous to reusable flexible ureteroscopes in regard to standard technical metrics. Depending on its purchase cost it may also represent a cost saving for hospitals when compared to the cumulative costs of maintaining reusable scopes. Additionally, urologist may consider using the scope in cases in which reusable scope damage is anticipated.

In vitro, in vivo, and clinical tests of a novel flexible ureteroscope for the diagnosis and treatment of kidney and ureteral diseases

Purpose

Despite advances in flexible ureteroscopy, the high cost and long repair time of ureteroscopes limit their use in the urology. We compared the performance of a novel flexible ureteroscope (fURS) 'HF-EH' with that of the two contemporary fURSs 'URF-P6' and 'COBRA'.

Materials and Methods

We compared in vitro measurements of deflection angle, irrigation flow rate, and image quality between HF-EH and URF-P6 while also inspecting renal collecting systems in five female pigs. For clinical testing, we performed retrograde intrarenal surgeries using HF-EH in four patients. Experienced urologists compared performance parameters (irrigation, convenience, and maneuverability) between the HF-EH and COBRA.

Results

The flow rate of HF-EH (21.0 mL/min) was worse, and its resolution (1.59 line pairs/mm) was inferior to that of URF-P6 (28.7 mL/min and 3.17 line pairs/mm, respectively). However, HF-EH was superior to URF-P6 in terms of loss of deflection angle with the insertion of accessories (1.8% vs. 12.7%). In vivo and clinical testing revealed that the performance parameters of HF-EH were slightly inferior to those of conventional domestic fURSs. We successfully performed retrograde intrarenal surgeries using HF-EH in four patients and achieved stone-free statuses in two. None of the patients exhibited any procedure-related complications.

Conclusions

Although we observed that two of the three performance parameters of the novel ureteroscope 'HF-EH' were inferior to those of the conventional ureteroscope, we successfully used HF-EH to perform retrograde intrarenal surgeries in patients. Further studies on performance and durability are warranted for making HF-EH commercially available.

Trends in the treatment of urinary stone disease in Turkey

Introduction

In this study, a survey was prepared for urologists that asked about their primary choice of treatment for urolithiasis in daily practice and their answers were evaluated.

Methods

The survey was prepared on the Google Docs website and it was sent to 1,016 urologists via email with 752 confirmed deliveries. In addition to the demographic questions about each participant's age, gender, and institution, the survey presented case scenarios focusing on their preferred treatment modalities for distal ureteric, proximal ureteric, and renal calculi. The participating urologists were divided into two groups according to the frequency that they treat urolithiasis patients.

Results

Of the 752 surveys delivered, 211 urologists (28.05%) responded and 204 answered all questions. According to the results, there were no significant differences between the treatment approaches and the other localizations, but there was a statistically significant difference for treatment approaches to lower pole stones between two groups. In response to the question of which stone treatment method was used less frequently, 124 (60.7%) participants answered that they used shock wave lithotripsy less in the last 10 years.

Conclusion

The present study has shown that while the management of renal and ureteric calculi by Turkish urologists is highly varied, the overall treatment patterns are in accordance with the European Association of Urology guidelines. However, similar to the global trend extracorporeal shock wave lithotripsy is less preferred by Turkish urologists.

Retrograde intrarenal surgery: An expanding role in treatment of urolithiasis

During the past 3 decades, the surgical management of kidney stones has undergone many technological advances and one is the development of the flexible ureteroscopy. The development of this instrument as well as ancillary equipment such as baskets, graspers, and others, and improvements in lithotripsy with Holmium: YAG laser have led to expand its indications with diagnostic and therapeutic management of medical issues of the upper urinary tract such as urolithiasis and urothelial tumors. The objective of this review is to describe its indications and results in the different scenarios for the treatment of urinary stones.

Current trends of percutaneous nephrolithotomy in a developing country

Introduction

To present the current practice patterns on percutaneous nephrolithotomy (PCNL) in a developing country.

Materials and Methods

A survey was offered to Brazilian urologists during the II International Endourology Symposium held in Sao Paulo, in 2015. The first seven questions were related to demographic data while the 20 remaining were directed to urologists who performed PCNL.

Results

From 250 participants, 100 replied to the survey, 81% performed PCNL and 60.4% of performers had been in practice for less than 15 years. Eighty-one percent were trained in the prone position and 64% in supine. PCNL was learned during the residency in 66.7% and 2.5% had fellowship training. Prone position was the preferred decubitus for simple or complex calculi, though for obese patients there was no difference. Younger surgeons prefer supine while older surgeons prefer prone. The access was obtained by the surgeon in all cases, 96.3% use fluoroscopy and 3.7% prefer ultrasonography. Forty-seven percent use ultrasonic lithotripters and 4.1% laser. For kidney drainage, 71.6% place a nephrostomy tube. Double J stent is left in 77%. The postoperative image method was CT for 50%. Colonic injury was reported by 25%, predominantly in the senior group without statistically difference between positions.

Conclusions

From a selected group of urologists, we observe that Brazilian urologists usually gain their own access for PCNL guided by fluoroscopy. They predominantly prefer the prone position, use fascial dilators, ultrasonic lithotripters and place a nephrostomy tube when exiting the kidney. Fellowship programs, ultrasonography, flexible nephoscopy and tubeless procedures could be encouraged.

Worldwide Trends of Urinary Stone Disease Treatment Over the Last Two Decades: A Systematic Review

INTRODUCTION

Numerous studies have reported on regional or national trends of stone disease treatment. However, no article has yet examined the global trends of intervention for stone disease.

METHODS AND MATERIALS

A systematic review of articles from 1996 to September 2016 for all English language articles reporting on trends of surgical treatment of stone disease was performed. Authors were contacted in the case of data not being clear. If the authors did not reply, data were estimated from graphs or tables. Results were analyzed using SPSS version 21, and trends were analyzed using linear regression.

RESULTS

Our systematic review yielded 120 articles, of which 8 were included in the initial review. This reflected outcomes from six countries with available data: United Kingdom, United States, New Zealand, Australia, Canada, and Brazil. Overall ureteroscopy (URS) had a 251.8% increase in total number of treatments performed with the share of total treatments increasing by 17%. While the share of total treatments for percutaneous nephrolithotomy (PCNL) remained static, the share for extracorporeal shockwave lithotripsy and open surgery fell by 14.5% and 12%, respectively. There was significant linear regression between rising trends of total treatments year on year for URS (p < 0.001).

CONCLUSION

In the last two decades, the share of total treatment for urolithiasis across the published literature has increased for URS, stable for PCNL, and decreased for lithotripsy and open surgery.

Ureteroscopy from the recent past to the near future

Stone surgery is one of oldest surgical practices undertaken by man. Hippocrates refused to let his followers "cut for the stone" and it was only in February 1980, when the first human trial of shock wave therapy on a renal stone was performed with success that a new era in minimally invasive treatment (surgery) for stones was opened up and this condemnation was finally resolved in the Hippocratic Oath. Endoscopy, using natural orifices, supported by anaesthesia, incremented by technology and with access to all points along the urinary tract, began by competing with ESWL, but is now the treatment of choice in most cases. As far as we know humans have always had stones. First, lithiasis was endemic bladder stones in children, now it is renal in general. Added to this a number of well-known risk factors, a rapid increase in obesity in the population, as well as bariatric surgery for its treatment, are causing an increase in the prevalence and recurrence of lithiasis everywhere. A short history of the advances made with the introduction and development of the ureteroscope, along with auxiliary devices, will show why this is the preferred technique at the moment for treating lithiasis in general and for treating stones in pregnant women, children and the obese in particular. Being a minimally invasive surgery, with a low morbidity and a very high efficiency and stonefree rate, has become established as a clear future technique for both adults and children. This development is not only due to technological advancements, but also to the routine use of the Holmium: YAG LASER for intracorporeal lithotripsy, capable of destroying any stone regardless of its composition or location, surpassing the ability of any other lithotripter. It is also due to the development of devices that allow access to the ureter and all parts of the kidney, as well as auxiliary aids to assist in the handling of stones during treatment. New LASERs, robotic control of the fdURS and digital imaging, as well as disposable devices, have had and, indeed, continue to have a unique impact on future development in this field. However, success will continue to depend on the careful choice of fURS, energy source and ancillary instruments obtained by the urologist during both real life and virtual training in human simulators.

Mini PCNL for renal calculi: does size matter?

OBJECTIVE

To evaluate the minimally invasive percutaneous nephrolithotomy (MIP) system for renal calculi.

PATIENTS AND METHODS

Consecutive patients undergoing mini-percutaneous nephrolithotomy (mPCNL) procedures with the MIP system were enrolled. Patient position, American Society of Anesthesiologists classification, puncture location, stone clearance, postoperative drainage and complications were recorded, and features unique to MIP were noted.

RESULTS

In all, 30 patients underwent 32 mPCNL procedures. The mean stone size was 17 (10.75-21.25) mm and the mean number of stones was 1 (1-2). The median stone clearance rate was 96.5 (95-100)%. The complication rate was 9.3%. No patient required a transfusion. In addition to these outcomes, we noted that the MIP system has many advantages over conventional PCNL (cPCNL). It is easy to learn and can be performed in both supine and prone positions. It is safe for supracostal puncture, provides excellent access to nearly all calyces and upper ureter, has multiple stone treatment options, can be used as an adjunct to cPCNL, and can be performed as a tubeless procedure.

CONCLUSION

Our experience with the MIP system has shown several advantages over cPCNL. mPCNL with the MIP system has several features that suggest it should be considered as an alternative or adjunct to cPCNL, ureteroscopy and extracorporeal shockwave lithotripsy.

Burden of Urolithiasis: Trends in Prevalence, Treatments, and Costs

CONTEXT

The recent evolution of management options for urolithiasis has presented a unique dilemma for the modern urologist. A comprehensive understanding of epidemiological trends along with current provider preferences in treating urinary stones would be beneficial.

OBJECTIVE

To review trends in the prevalence, treatments, and costs of urolithiasis worldwide.

EVIDENCE ACQUISITION

A literature review was performed using the MEDLINE database, the Cochrane Library Central search facility, Web of Science, and Google Scholar between 1986 and 2016. Keywords used for the search were "urolithiasis" and "prevalence; treatment; and cost".

EVIDENCE SYNTHESIS

The incidence and prevalence of urinary stones are rising around the world, including regions that have historically had low rates of urolithiasis. Common theories explaining this trend involve climate warming, dietary changes, and obesity. Shockwave lithotripsy (SWL) has been the preferred mode of treatment since its introduction in the 1980s. However, ureteroscopy (URS) has become increasingly popular for small stones regardless of location because of lower recurrence rates and costs. Developing countries have been slower to adopt URS technology and continue to use percutaneous nephrolithotomy at a steady rate.

CONCLUSIONS

URS has recently challenged SWL as the treatment modality preferred for small upper urinary tract stones. In some cases it is less expensive but still highly effective. As the burden of stone disease increases worldwide, appropriate selection of stone removal therapies will continue to play an important role and will thus require further investigation.

PATIENT SUMMARY

Urinary stones are becoming more prevalent. Recent advances in technology have improved the management of this disease and have decreased costs.

Lubriglide Sequential Ureteral Dilators®: A Safe and Effective Method of Ureteral Dilation

INTRODUCTION

During ureteroscopy (URS), ureteral dilation may be required to increase the likelihood of accessing the ureter to complete the procedure. Thus, we sought to assess the safety and efficacy of using Lubriglide sequential ureteral dilators^® (Boston Scientific) to promote primary URS, without need for prestenting.

PATIENTS AND METHODS

Retrospective review was performed of a consecutive series of patients undergoing primary URS by a single surgeon (N.L.M.) from 2011 to 2013. The primary outcomes were to characterize the use, safety, and efficacy of sequential ureteral dilators to promote stone treatment during URS.

RESULTS

A total of 316 nonprestented cases of primary URS were attempted over the study period. Use of sequential ureteral dilators to promote ureteral access was performed in 109 (34.5%) cases and was effective to allow completion of the procedure in 102 (93.6%) cases. No intraoperative complications occurred while performing sequential ureteral dilation. Fourteen patients (4.3%) required ureteral stent placement for passive ureteral dilation, with definitive stone treatment at a later date. Postoperative radiographic follow-up was available for 272 (86.1%) cases, and no ureteral strictures were detected in the ureteral dilation group. On multivariate analysis, both a history of prior extracorporeal shockwave lithotripsy [odds ratio (OR) 0.45, confidence interval (CI) 0.25, 0.81, p = 0.008] and prior URS (OR 0.42, CI 0.25, 0.70, p = 0.001) were inversely associated with need to perform ureteral dilation.

CONCLUSIONS

Approximately 1/3 of nonprestented patients may require ureteral dilation for effective completion of primary URS. Use of sequential ureteral dilators may significantly decrease the need for prestenting and a secondary procedure to complete stone treatment. Thus, we conclude that sequential ureteral dilators represent a safe and effective method to perform ureteral dilation to promote ureteral access and allow for effective stone treatment in one setting.

Devices to help combat stone retropulsion during ureteroscopic lithotripsy in 2016

Proximal migration of stones during ureteroscopic lithotripsy is a common problem that faces many urologists and reduces stone-free rates, which translates into higher costs and longer operative times. In a bid to increase stone-free rates, there are several anti-retropulsion devices on the market, to help urologists during ureteroscopic lithotripsy. We previously reviewed these anti-retropulsion devices and wish to update what is currently available on the market.

National Practice Pattern and Time Trends in Treatment of Upper Urinary Tract Calculi in Korea: a Nationwide Population-Based Study

Despite high prevalence of upper urinary tract calculi (UUTC), there are few studies regarding patterns of care in Asian populations. We investigated treatment patterns and time trends in patients with newly diagnosed UUTC in Korea using the National Health Insurance database that includes de-identified claims from a random 2% sample of the entire population (> 1 million people). A total of 14,282 patients who received active treatments, including shock wave lithotripsy (SWL), ureteroscopic surgery (URS), percutaneous nephrolithotomy (PNL), and uretero/pyelolithotomy (UPL), for newly diagnosed UUTC between 2003 and 2013 were included. The number of primary and all treated cases of UUTC significantly (43% and 103.3%, respectively) increased over the 10-year period. While patients undergoing SWL, URS, PNL, and UPL as primary treatment increased by 43.7%, 31.9%, 87.5%, and 0%, respectively, the relative proportion undergoing each treatment remained constant over the 10 years (SWL > 90%, URS 4.5% to 7.8%, PNL 0.4% to 1.0%, and UPL < 0.4%, respectively). Multinomial logistic regression analysis showed that age > 40 years (compared to age < 30 years) was significantly associated with URS, PNL, and UPL, rather than SWL, while patients living in urban or suburban/rural areas (compared to metropolitan) were significantly less likely to undergo URS and PNL. In summary, the majority of Korean patients underwent SWL as primary treatment for UUTC, and the predominant use of SWL remained steady over a 10-year period in Korea. Our results will be valuable in examining treatment patterns and time trends in Korean UUTC patients.

Percutaneous Nephrolithotomy Increases the Risk of New-onset Hypertension: A Nationwide 6-Year Follow-up Study

OBJECTIVE

To determine whether percutaneous nephrolithotomy or ureteroscopic lithotripsy leads to the development of hypertension, using the Taiwan National Health Insurance database.

METHODS

Data were sourced from the Longitudinal Health Insurance Database (LHID2000) of Taiwan, Republic of China, compiled by the Taiwan National Health Insurance database from 1996 to 2010. Percutaneous nephrolithotomy and ureteroscopic lithotripsy were studied as time-dependent covariates in a Cox proportional hazard model to estimate the hazard ratio for the effect of new-onset hypertension.

RESULTS

A total of 2552 patients were included, with 232 PNL percutaneous nephrolithotomy, 1160 ureteroscopic lithotripsy patients, and 1160 comparison patients. There was a significant difference between the incidence of new-onset hypertension between the percutaneous nephrolithotomy and comparison groups (adjusted hazard ratio 1.48, 95% confidence interval 1.13-1.95, P = .005). The percutaneous nephrolithotomy group also had a higher incidence of new-onset hypertension than the ureteroscopic lithotripsy group (adjusted hazard ratio 1.39, 95% confidence interval 1.06-1.83, P = .018). The incidence rate of new hypertension during the follow-up period was 44.5 per 1000 person-years in the percutaneous nephrolithotomy group, 33.0 per 1000 person-years in the ureteroscopic lithotripsy group, and 30.2 per 1000 person-years in the comparison group.

CONCLUSION

An association exists between nephrolithiasis patients who were treated with percutaneous nephrolithotomy and subsequent hypertension diagnosis. Although the exact mechanisms for this phenomenon are not clear, patients who undergo percutaneous nephrolithotomy may need close monitoring of blood pressure during postoperative follow-up.

Shock wave lithotripsy (SWL): outcomes from a national SWL database in New Zealand

OBJECTIVES

To present the national outcomes for New Zealand of over 9000 stone cases treated with SWL at 21 centres over a 20 year period.

SUBJECTS/PATIENTS AND METHODS

Stone cases treated with SWL on board the Mobile Medical Technology (MMT) vehicle between 19 June 1995 and 1 December 2014 were identified, and data collection undertaken prospectively for patient, stone and treatment characteristics, and retrospectively for treatment outcomes. The primary outcome was treatment success, defined as complete stone clearance or clinically insignificant residual fragments (CIRFs) of ≤4 mm. Secondary outcomes were stone free rate, complications and auxiliary procedures, and all statistical analyses were descriptive.

RESULTS

9538 stone cases (7769 patients) were included. The overall, cumulative success rate was 58.7%; this included 45.1% that were stone free and 13.5% in which there were CIRFs ≤4 mm. Success rates varied widely by stone size and location. Overall rates of urinary tract infection, perinephric haematoma, hospital admission and ureteral stent placement were 1.1%, 0.2%, 6.8% and 4.1%, respectively. Variations in SWL protocols across centres limits the overall reliability of our findings.

CONCLUSION

SWL remains a low morbidity management option requiring careful patient selection. This study provides valuable data for patient counseling and the formation of evidence based guidelines in SWL. The MMT SWL service has demonstrated that is it possible to deliver a high volume specialist stone service without requiring patients to travel further for treatment.

Retrograde ureteric stent insertion in the management of infected obstructed kidneys

OBJECTIVES

To quantify the outcomes of retrograde ureteric stenting in the setting of infected hydronephrosis secondary to ureteric calculi.

PATIENTS AND METHODS

Prospective analysis of all patients over a 15-month period admitted with infected obstructed kidneys secondary to ureteric calculi. Inclusion criteria were based on clinical evidence of systemic inflammatory response syndrome (SIRS) and radiological evidence of obstructing ureteric calculi. Outcome measures included success of procedure, admission to intensive care unit (ICU), length of hospital stay, morbidity, and all-cause mortality during hospital admission.

RESULTS

In all, 52 patients were included. Success of retrograde ureteric stenting was 98%. In all, 17% of patients required an ICU admission, with a post ureteric instrumentation ICU admissions rate of 6%. The mean white cell count and serum creatinine improved significantly after the procedure. Major complication rate included septic shock 6%, but there were no episodes of major haemorrhage and no deaths.

CONCLUSION

Retrograde ureteric stenting is safe and effective in infected obstructed kidneys with results comparable to percutaneous nephrostomy tube insertion. Post instrumentation ICU admissions occur in 6% of retrograde stentings.

Invasive treatment trends in urinary calculi in a third level hospital

OBJECTIVE

In the following study, we observe the progress of various invasive calculi treatments that have taken place in our hospital in the last 15 years.

MATERIAL AND METHOD

We extracted data from our hospital database on patients who underwent extracorporeal shock wave lithotripsy (ESWL), endoscopic surgery and open surgery. We analyzed how the incidence of these treatments has evolved over the last 15 years. We also studied the number of publications in PubMed that reference invasive calculi treatments.

RESULTS

From January 1998 to December 2012, a total of 10,947 patients were treated instrumentally for lithiasis, 9,695 of whom (90.4%) underwent ESWL and 1,034 of whom underwent endoscopic or open surgery (9.6%). The incidence of lithotripsy treatments reached its maximum in 2006, with a progressive reduction thereafter. The incidence of endoscopic surgery increased progressively until 2009 and then leveled off. We can see how in recent years there has been a clear increase in the number of studies that have covered endoscopic surgery, with a decreasing number covering ESWL.

CONCLUSIONS

In our community, ESWL remains the most widely used invasive treatment for calculi. In recent years, there has been a reduction in the number of ESWL treatments and an increase in the number of endoscopic treatments, with open surgery showing a clearly decreasing trend.

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.

The surgical management of kidney stone disease: a population based time series analysis

PURPOSE

We evaluate population based trends in the use of extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy during the last 20 years, as well as assess the re-treatment rate and morbidity from treatment over time.

MATERIALS AND METHODS

Using administrative databases in the province of Ontario, Canada, a population based cross-sectional time series analysis was performed between July 1, 1991 and December 31, 2010. All extracorporeal shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy procedures were identified, along with all hospital readmissions and emergency department visits within 7 days of treatment. The primary outcome was treatment use, and secondary outcomes were the need for ancillary treatment and hospital readmission or emergency department visit after treatment. Exponential smoothing and autoregressive integrated moving average (ARIMA) models were used to assess trends over time.

RESULTS

We identified 194,781 kidney stone treatments performed during the study period. Time series modeling revealed a significant increase in the use of ureteroscopy over time (25% to 59% of all procedures, p <0.0001) and a reciprocal decrease in the use of extracorporeal shock wave lithotripsy (69% to 34% of all procedures, p <0.0001). A corresponding significant decrease in the need for ancillary treatment over time (23% to 15%, p <0.0001) and increase in the need for hospital readmission (7% to 11%, p <0.0001) or emergency department visit (7% to 11%, p=0.0024) after treatment were also demonstrated.

CONCLUSIONS

Our population based study demonstrates a shift in the treatment paradigm with increased use of ureteroscopy over time and a reciprocal decrease in the use of extracorporeal shock wave lithotripsy. We also observed a corresponding decrease in ancillary treatment and increase in posttreatment morbidity over time.

In vitro fragmentation efficiency of holmium: yttrium-aluminum-garnet (YAG) laser lithotripsy--a comprehensive study encompassing different frequencies, pulse energies, total power levels and laser fibre diameters

OBJECTIVE

To assess the fragmentation (ablation) efficiency of laser lithotripsy along a wide range of pulse energies, frequencies, power settings and different laser fibres, in particular to compare high- with low-frequency lithotripsy using a dynamic and innovative testing procedure free from any human interaction bias.

MATERIALS AND METHODS

An automated laser fragmentation testing system was developed. The unmoving laser fibres fired at the surface of an artificial stone while the stone was moved past at a constant velocity, thus creating a fissure. The lithotripter settings were 0.2-1.2 J pulse energies, 5-40 Hz frequencies, 4-20 W power levels, and 200 and 550 μm core laser fibres. Fissure width, depth, and volume were analysed and comparisons between laser settings, fibres and ablation rates were made.

RESULTS

Low frequency-high pulse energy (LoFr-HiPE) settings were (up to six times) more ablative than high frequency-low pulse energy (HiFr-LoPE) at the same power levels (P < 0.001), as they produced deeper (P < 0.01) and wider (P < 0.001) fissures. There were linear correlations between pulse energy and fragmentation volume, fissure width, and fissure depth (all P < 0.001). Total power did not correlate with fragmentation measurements. Laser fibre diameter did not affect fragmentation volume (P = 0.81), except at very low pulse energies (0.2 J), where the large fibre was less efficient (P = 0.015).

CONCLUSIONS

At the same total power level, LoFr-HiPE lithotripsy was most efficient. Pulse energy was the key variable that drove fragmentation efficiency. Attention must be paid to prevent the formation of time-consuming bulky debris and adapt the lithotripter settings to one's needs. As fibre diameter did not affect fragmentation efficiency, small fibres are preferable due to better scope irrigation and manoeuvrability.

Damage of stone baskets by endourologic lithotripters: a laboratory study of 5 lithotripters and 4 basket types

Background. In some cases, the ureteral stone is simultaneously stabilized by a stone basket when endourologic lithotripsy is performed. This stabilization can be either on purpose or by accident. By accident means that an impaction in the ureter occurs by an extraction of a stone with a basket. A stabilization on purpose means to avoid a retropulsion of the stone into the kidney during lithotripsy. At this part of the operation, stone baskets have been frequently damaged. This severing of wires can lead to ureteral trauma because of hook formation. Material and Methods. In a laboratory setting, the time and the pulse numbers were measured until breaking the wires from four different nitinol stone baskets by using five different lithotripsy devices. The endpoint was gross visibledamage to the wire and loss of electric conduction. Results. The Ho:YAG laser and the ultrasonic device were able to destroy almost all the wires. The ballistic devices and the electrohydraulic device were able to destroy thin wires. Conclusion. The operating surgeon should know the risk of damagefor every lithotripter. The Ho:YAG-laser and the ultrasonic device should be classified as dangerous for the basket wire with all adverse effects to the patient.