Management of kidney stones

Treatment modalities for small-sized urolithiases and their impact on health-related quality of life

INTRODUCTION

Health-related quality of life (HRQoL) is often reduced in patients with urolithiasis. The objective of this study was to perform a systematic review to describe impact on HRQoL based on different modalities of treatment for small urolithiases with a diameter smaller or equal to 10 mm.

METHODS

Electronic databases were searched with no language or date restrictions to identify studies which were included if they reported: adult patients (≥18 years old), renal or ureteral stone(s) confirmed on imagery, validated reporting of HRQoL, stone diameter equal or smaller than 10 mm undergoing active surveillance, medical expulsive therapy (MET), shockwave lithotripsy (SWL), or ureteroscopy (URS).

RESULTS

Of 672 citations, nine articles were eligible. Five studies (all ureteral) reported HRQoL according to medical stone management. Three of them found that HRQoL in MET patients was better than in active surveillance patients and two studies found no difference in HRQoL between MET and active surveillance groups. Four studies (three ureteral, one renal) reported HRQoL according to surgical stone management. Of the ureteral stone studies, two reported better HRQoL in URS patients than in SWL patients, while one study found no difference between URS and SWL groups. In the renal stone study, SWL patients had better HRQoL than URS patients.

CONCLUSIONS

Patients with urinary stones 10 mm or smaller have better HRQoL when treated with MET vs. active surveillance, when treated with SWL vs. URS for renal stones, and when treated with URS vs. SWL for ureteral stones. There is an important need for more studies on this topic.

Predictors of acute kidney injury after percutaneous nephrolithotomy in adult patients: prospective observational study

PURPOSE

To assess the frequency and the predictive factors of Acute Kidney injury (AKI) in patients undergoing percutaneous nephrolithotomy (PNL).

METHODS

A prospective observational work. Demographic, preoperative laboratory data, stone characteristics, and intraoperative and postoperative data were gathered. Perioperative AKI had been defined as an elevation in serum creatinine by ≥ 0.3 mg/dl within 48 h, or ≥ 1.5 times baseline, or urine volume less than 0.5 ml/ kg/hour for 6 hours. A multivariate logistic regression analysis was performed to determine the predictive factors of AKI. ROC curves were utilized to determine the cutoff values of the risk variables. P-values were deemed statistically significant when they were less than 0.05.

RESULTS

A total of 418 participants had been involved. The frequency of AKI was 13.9, and 17.2% of patients with AKI developed CKD. The risk factors were age > 46.5 years, smoking, BMI > 28.5 kg/m2, hypertension, diabetes, utilization of angiotensin-converting enzyme inhibitors (ACEI), haemoglobin < 10.8 gm/dl, baseline creatinine > 1.41 mg/dl, eGFR < 65.2 ml/min./1.73 m2, serum uric acid > 5.2 mg/dl, stone volume > 1748 mm3, large tract size, long operative time, and intra-operative bleeding. Patients with AKI had a notably extended duration of hospitalization (3.2 days ± 0.45 vs 2.1 ± 0.42, p < 0.001).

CONCLUSIONS

Perioperative AKI occurred in 13.9% of individuals undergoing PNL. Identification and optimization of the risk factors and meticulous technique during PNL procedures should be attempted to decrease the risk of AKI.

Intradermal Sterile Water Injection: Safe and Effective Alternative for Relief of Acute Renal Colic in the Emergency Department

BACKGROUND

The optimal pain relief method for acute renal colic in the emergency department remains controversial.

OBJECTIVE

We compared the safety and efficacy of intradermal sterile water injection (ISWI) to treatment with intramuscular (IM) diclofenac, intravenous (IV) opioids, and IV paracetamol in patients with acute renal colic.

METHODS

This randomized, single-blind study included 320 patients with renal colic to one of four treatment groups. The first group received ISWI at four different points around the most painful flank area. Patients in the DI, PARA, and TRAM groups received 75 mg IM diclofenac, 1 g IV paracetamol, and 100 mg IV tramadol, respectively. Pain intensity was measured using a visual analog scale (VAS) before treatment and 15, 30, and 60 min after treatment.

RESULTS

VAS scores 15 and 30 min after treatment were significantly lower in group ISWI than in groups DI, PARA, and TRAM. However, there were no significant differences in the decrease in the pain score at baseline and at 60 min after treatment. In addition, fewer patients required rescue analgesia in group ISWI than in group TRAM. However, no significant differences were observed between group ISWI and group DI or PARA in terms of the need for rescue analgesia. Finally, there were significantly fewer adverse events in group ISWI than in groups DI and TRAM.

CONCLUSIONS

ISWI had similar efficacy, faster pain relief, and lower need for rescue analgesia compared with diclofenac, paracetamol, and tramadol for the management of acute renal colic. In addition, ISWI was well-tolerated and had no adverse effects.

Therapeutic effects of probiotics and herbal medications on oxalate nephrolithiasis: a mini systematic review

Background and Objectives

The majority of all kidney stone cases are oxalate urolithiasis with a high risk of recurrence. Beside its widespread occurrence, kidney stones are characterized by severe complications and high treatment costs. Probiotics and herbal medications could be forthcoming therapeutic interventions in the management of oxalate kidney stones.

Materials and Methods

The PubMed/MEDLINE database was searched for keywords "Oxalobacter formigenes" AND "Oxalate" OR "oxalate degradation" AND "Lactobacillus" OR "Bifidobacterium" OR "recombinant Lactobacillus" OR "Bacillus subtilis", and "urolithiasis" AND "herbal extract". The search returned 253 results, 38 of which were included in the review.

Results

Most of the oxalate-degrading probiotics belong to the Oxalobacter formigenes, Lactobacillus, Bifidobacterium, and Bacillus genus with a minimum dosage of 107 CFU in the form of capsules, sachets, and lyophilized powder. Oxalate concentration in media was 5-50mM with an incubation time ranging from 24h to 14 days. The majority of the studies suggested that probiotic supplementation might be useful for reducing urinary excretion of oxalate and urea and alleviation of stone formation. Different herbal extracts were used on murine models of nephrolithiasis (induced by 0.5-3% ethylene glycol) with reduction of renal inflammation and urinary parameters, and calcium oxalate crystals.

Conclusion

Several strains of probiotics and herbal extracts confer protective effects against kidney stone/nephrolithiasis, indicating their promising nature for being considered as elements of preventive / adjuvant therapeutic strategies.

Laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones

The purpose of the study was to introduce a novel surgical approach of combining laparoscopic pyelotomy with ultrasonic lithotripsy via a nephroscope for the treatment of complex renal stones. Between May 2021 and April 2023, 32 patients underwent laparoscopic pyelotomy combined with ultrasonic lithotripsy via a nephroscope and their perioperative variables were retrospectively collected and outcomes were assessed. Dissection and incision of the anterior renal pelvis wall was performed via a laparoscope. A 19.5 F nephroscope was introduced into the renal pelvis through a laparoscopic trocar from the incision. Stones were fragmented and sucked out using a 3.3 mm ultrasonic probe placed through the nephroscope. All operations were completed successfully and the stone-free rate at 3 days after operation was 87.5% (28/32). Four (12.5%, 4/32) patients with staghorn stones had a small residual stone in the lower calyx after operation and did not require reintervention. No patient required perioperative transfusion and four (12.5%, 4/32) patients with struvite stones developed postoperative fever, which was successfully treated with intravenous antibiotics. The mean follow-up time was 14.0 ± 7.2 months, with no patient developing long-term complications. This approach offers a safe and effective treatment option for complex renal stones, as the method exhibits a high clearance rate with few complications.

Impact of frailty on clinical outcomes and resource utilization of hospitalizations for renal stone surgery

PURPOSE

Frailty is reportedly associated with poorer outcomes among surgical patients. Using a coding-based frailty tool, we investigated the impact of frailty on clinical outcomes and resource utilization for urolithiasis hospitalizations.

METHODS

A cohort study using the 2018 National Inpatient Sample database. All adult elective hospitalizations for urolithiasis were included in the study. The study population was categorized into FRAIL and non-frail (nFRAIL) cohorts using the Johns Hopkins Adjusted Clinical Groups frailty clusters. The association between frailty and clinical and financial outcomes was evaluated using multivariate regression models.

RESULTS

About 1028 (14.9%) out of 6900 total hospitalizations were frail. Frailty was not associated with a significant increase in the odds of in-hospital mortality (adjusted odds ratio (aOR) 1.73, 95% CI 0.15-20.02) or length of hospital stay, but was associated with a lower chance of surgery within 24 h of admission (aOR 0.65, 95% CI 0.48-0.90, P = 0.008). A higher Charlson index was independently associated with an over 100% increase in the odds of in-hospital mortality (aOR 2.091, 95% CI 1.53-2.86, P < 0.001). Frail patients paid $15,993 higher in total hospital costs and had a higher likelihood of non-home discharges (aOR 4.29, 95% CI 2.74-6.71, P < 0.001) and peri-operative complications (aOR 1.77, 95% CI 1.14-2.73, P = 0.01).

CONCLUSION

Frailty was correlated with unfavorable outcomes, except mortality and prolonged hospital stay. Incorporating frailty evaluation into risk models has the potential to enhance patient selection and preparation for urolithiasis intervention.

A systematic review of postoperative outcomes of kidney stone surgery and meta-analysis of outcomes of percutaneous nephrolithotomy in individuals with spinal cord injury

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

To evaluate outcomes of surgical treatment for nephrolithiasis in individuals with spinal cord injury (SCI).

METHODS

We systematically reviewed the Ovid MEDLINE, Embase, CENTRAL, and Web of Science databases for studies examining outcomes of kidney stone procedures in individuals with SCI. Our primary outcomes were stone-free rate (SFR) and complications as categorized by Clavien-Dindo classification. A meta-analysis of comparative studies was performed to assess differences in SFR and complication rate between individuals with and without SCI following PCNL.

RESULTS

A total of 27 retrospective and observational articles were included. Interventions for kidney stones included PCNL, shockwave lithotripsy (SWL), and ureteroscopy. Pooled SFR in individuals with SCI was 54%, for SWL, 74% for PCNL, and 36% for ureteroscopy. Meta-analyses found that there was higher rate of grades I (OR 9.54; 95% CI, 3.06 to 29.79), II (OR 3.38; 95% CI, 1.85 to 6.18), and III-V (OR 2.38; 95% CI, 1.35 to 4.19) complications in individuals with SCI compared to non-SCI individuals following PCNL. The rate of infectious complications was also higher in individuals with SCI (OR 6.15; 95% CI, 1.86 to 20.39). However, there was no difference in SFR (OR 0.64; 95% CI, 0.15 to 2.64) between groups.

CONCLUSIONS

Individuals with SCI are at higher risk of minor, major, and infectious complications following PCNL compared to non-SCI individuals. There was no significant difference between groups in SFR following PCNL, suggesting that PCNL is an effective surgery for kidney stones in individuals with SCI.

Renal cell carcinoma in a patient with staghorn stones: A case report

INTRODUCTION AND IMPORTANCE

Staghorn stone fills the renal pelvic and two or more branches of renal calyces. The incidence of staghorn stones is between 10 and 20 % of all urinary tract stones. We report the case of a man with right staghorn stones and renal mass who underwent right radical nephrectomy with pathology anatomy result of renal cell carcinoma (RCC).

CASE PRESENTATION

A 56-year-old man came with a complaint of right flank pain for two months. Physical examination is within normal limits, but an abdominal CT scan revealed a staghorn stone with enhancing mass in the upper pole of the right kidney. Patient subsequently underwent right radical nephrectomy. Pathology examination revealed RCC.

CLINICAL DISCUSSION

The presence of kidney stones in renal malignancy is rare. Kidney stones can be a risk factor for renal cell malignancy, and renal cell malignancies can cause urinary stasis, making it a risk factor for kidney stones. A study conducted by Nugroho and colleagues concluded that renal and caliceal biopsy should be considered in large and chronic renal stone due to potential experiencing kidney malignancy in patient with renal stone. Therefore, early diagnosis and definitive can be carried out.

CONCLUSION

Kidney stones and malignancy are rarely found. Renal pelvis, and caliceal wall biopsy should be considered in chronic and large renal stone, especially staghorn stone in patient that did not have any signs of malignancy on CT scan. Treatment in such case is focused on the oncological outcome. Therefore, radical nephrectomy is the treatment of choice.

Efficacy and safety of super-mini percutaneous nephrolithotomy in the treatment of urinary calculi: a systematic review and meta-analysis

BACKGROUND

Super-mini-percutaneous nephrolithotomy (SMP) is feasible and safe in adults and children with moderate-size renal calculi, but the use of SMP to remove larger calculi has yet to be determined. This study aimed to review the efficacy (stone-free rate, SFR) and safety of SMP in treating urinary calculi.

METHODS

PubMed, the Cochrane Library, and Embase were searched for eligible studies published up to May 2021. The primary outcome was the SFR. The secondary outcomes were the complications (using the Clavien-Dindo grading system), pain score, hospitalization days, and mean hemoglobin decline. All analyses were performed using the random-effects model. Nine studies (2433 patients with SMP and 2178 controls) were included.

RESULTS

SMP was not associated with an improved SFR in patients with calculi (RR = 1.05, 95%CI: 0.99-1.11). There were no differences in the occurrence of Clavien-Dindo I (RR = 0.95, 95%CI: 0.67-1.35) and Clavien-Dindo II (RR = 0.91, 95%CI: 0.58-1.42) complications between SMP and the control procedures. There were more Clavien-Dindo III complications with SMP than with the control procedures (RR = 0.71, 95%CI: 0.55-0.91), but none of the individual complications significantly differed between the two groups. Clavien-Dindo I fever appeared to be higher with SMP than with the control procedure (RR = 0.64, 95%CI: 0.50-0.83).

CONCLUSION

In terms of efficacy, there were no differences between SMP and other procedures in treating urinary calculi. Clavien-Dindo I fever and Clavien-Dindo III complications might be more frequent with SMP than other procedures.

Efficacy of a Multicomponent Nutraceutical Formulation for the Prevention and Treatment of Urinary Tract Stones

Urolithiasis is a complex and multifactorial disease characterized by the formation of calculi at the urinary tract level. Conventional therapeutic prophylaxis relies on the use of Ca-blockers, alkalis, diuretics, and anti-edema agents, but their prolonged utilization is often limited by several side effects. In this scenario, the aim of the present work was the design of an innovative multi-component nutraceutical formulation (NF) for the management of urinary stones consisting of a synergistic combination of natural aqueous extracts of Oreganum vulgare L. (1% of saponin), Urtica dioica (0.8% of β-sitosterol), Phyllanthus niruri (15% of tannins w/w), and Ceterach officinarum in association with bromelain, K, and Mg citrate. To assess the potential of NF also in the treatment of uric acid (UA) stones, the effects on the expression of the cellular UA transporters OAT1 and URAT1 were investigated in a renal tubular cell line. In addition, the myorelaxant effect of NF was investigated in a human pulmonary artery smooth muscle cell (HPASMC) model resulting in a decreased muscle contractility of -49.4% (p < 0.01) compared to the control. The treatment with NF also showed a valuable inhibition of in vitro calcium-oxalate crystal formation, both in prevention (-52.3% vs. control, p < 0.01) and treatment (-70.8% vs. control, p < 0.01) experiments. Finally, an ischemic reperfusion rat model was used to evaluate the NF anti-edema effects, resulting in a reduction in the edema-related vascular permeability (Normalized Gray Levels, NGL = 0.40 ± 0.09, p < 0.01, -67.1% vs. untreated rats). In conclusion, the present NF has shown to be a promising natural alternative for managing urinary tract stones.

Dietary supplements and medicinal plants in urolithiasis: diet, prevention, and cure

BACKGROUND

Urolithiasis has been a major health concern for centuries, primarily owing to the limited treatment options in the physician's armamentarium. However, various studies have underscored a lesser incidence of urolithiasis in cohorts predominantly consuming fruits and vegetables. This article aims to review various dietary plants, medicinal herbs and phytochemicals in the prevention and management of urolithiasis.

METHODS

To provide context and evidence, relevant publications were identified on Google Scholar, PubMed and Science-Direct using keywords such as urolithiasis, nephrolithiasis, urolithiasis, renal stones, phytochemicals and dietary plants.

RESULTS

Growing bodies of evidence suggest the incorporation of plant-based foods, medicinal and herbal supplements, and crude drugs containing phytochemicals into the staple diet of people. The anti-urolithiatic activity of these plant bioactives can be attributed to their antioxidant, antispasmodic, diuretic, and inhibitory effect on the crystallization, nucleation and crystal aggregation effects. These mechanisms would help alleviate the events and symptoms that aid in the development and progression of renal calculi. In addition, it will also avoid the exacerbation of secondary disorders like inflammation and injury, which can initiate a vicious circle in turn worsening the disease progression.

CONCLUSION

In conclusion, the results presented in the review demonstrate the promising role of various dietary plants, medicinal and herbal supplements, and phytochemicals in preventing and managing the precipitation of uroliths. However, more conclusive and cogent evidence from preclinical and clinical studies is required to substantiate their safety, efficacy and toxicity profiles in humans.

Numerical investigation of shock-induced bubble collapse dynamics and fluid-solid interactions during shock-wave lithotripsy

In this paper we investigate the bubble collapse dynamics under shock-induced loading near soft and rigid bio-materials, during shock wave lithotripsy. A novel numerical framework was developed, that employs a Diffuse Interface Method (DIM) accounting for the interaction across fluid-solid-gas interfaces. For the resolution of the extended variety of length scales, due to the dynamic and fine interfacial structures, an Adaptive Mesh Refinement (AMR) framework for unstructured grids was incorporated. This multi-material multi-scale approach aims to reduce the numerical diffusion and preserve sharp interfaces. The presented numerical framework is validated for cases of bubble dynamics, under high and low ambient pressure ratios, shock-induced collapses, and wave transmission problems across a fluid-solid interface, against theoretical and numerical results. Three different configurations of shock-induced collapse applications near a kidney stone and soft tissue have been simulated for different stand-off distances and bubble attachment configurations. The obtained results reveal the detailed collapse dynamics, jet formation, solid deformation, rebound, primary and secondary shock wave emissions, and secondary collapse that govern the near-solid collapse and penetration mechanisms. Significant correlations of the problem configuration to the overall collapse mechanisms were found, stemming from the contact angle/attachment of the bubble and from the properties of solid material. In general, bubbles with their center closer to the kidney stone surface produce more violent collapses. For the soft tissue, the bubble movement prior to the collapse is of great importance as new structures can emerge which can trap the liquid jet into induced crevices. Finally, the tissue penetration is examined for these cases and a novel tension-driven tissue injury mechanism is elucidated, emanating from the complex interaction of the bubble/tissue interaction during the secondary collapse phase of an entrapped bubble in an induced crevice with the liquid jet.

Role of Kidney Stones in Renal Pelvis Flow

Ureteroscopy is a commonly performed medical procedure to treat stones in the kidney and ureter using a ureteroscope. Throughout the procedure, saline is irrigated through the scope to aid visibility and wash-out debris from stone fragmentation. The key challenge that this research addresses is to build a fundamental understanding of the interaction between the kidney stones/stone fragments and the flow dynamics in the renal pelvis flow. We examine the time-dependent flow dynamics inside an idealized renal pelvis in the context of a surgical procedure for kidney stone removal. Here, we examine the time-dependent evolution of these vortical flow structures in three dimensions, and incorporate the presence of rigid kidney stones. We perform direct numerical simulations, solving the transient Navier-Stokes equations in a spherical domain. Our numerical predictions for the flow dynamics in the absence of stones are validated with available experimental and numerical data, and the governing parameters and flow regimes are chosen carefully in order to satisfy several clinical constraints. The results shed light on the crucial role of flow circulation in the renal cavity and its effect on the trajectories of rigid stones. We demonstrate that stones can either be washed out of the cavity along with the fluid, or be trapped in the cavity via their interaction with vortical flow structures. Additionally, we study the effect of multiple stones in the flow field within the cavity in terms of the kinetic energy, entrapped fluid volume, and the clearance rate of a passive tracer modeled via an advection-diffusion equation. We demonstrate that the flow in the presence of stones features a higher vorticity production within the cavity compared with the stone-free cases.

A robust localization approach for Percutaneous Nephrolithotomy (PCNL): A single-center retrospective study

BACKGROUND

Percutaneous Nephrolithotomy (PCNL) represents the gold standard treatment method for cases with large kidney stones. As a critical step in performing PCNL, the procedure of establishing a safe and accurate nephrostomy tract will dramatically impact the treatment quality of patients with large-sized kidney stones.

OBJECTIVE

This work attempts to describe a new and improved process of establishing an accurate nephrostomy tract and clinically evaluate the effectiveness and safeness of this proposed methodology.

METHODS

This work represents a retrospective single-center study carried out between August 2013 and November 2019. The collected samples consist of 937 patients who were operated on using PCNL coupled with our proposed procedure. Briefly, a preoperative B-ultrasonography was firstly performed to decide the puncture point in a simulated surgical position where was marked with ureteral catheter segments (2-3 cm). A computed tomography (CT) scan was followed to correct the anchor points in the simulated surgical position. After this, an accurate puncture operation was performed under the real-time guidance of intraoperative B ultrasound.

RESULTS

Examining this study, 851 subjects with renal stones and 86 subjects with ureteropelvic junction stones were included for the PCNL operation project. All samples were grouped with Guy's grading system: grade I, II, III, and IV patients there were 0.00%, 42.69%, 51.01%, and 6.30%, respectively. Among these patients, the average age was 48.49 ± 10.80 years old, with a male to female ratio of around 1.73:1.

CONCLUSIONS

This study showed that our developed method warrants an accurate and safe PCNL operation that involves the process of establishing the nephrostomy tract. Other advantageous attributes of this new PCNL process include negligible radiation exposure, lesser complications, and low failure rates. More importantly, this new localization approach is particularly attractive for hospitals that are new to the field of adopting PCNL considering its safeness, effectiveness, and learnability.

Effects of stone density on alteration in renal resistive index after extracorporeal shock wave lithotripsy for non-obstructed kidney stones

Aim The doppler-based renal resistive index is a recently proposed technique for measuring changes in renal perfusion and predicting acute kidney damage. The purpose of this study was to look at the influence of stone density on the renal resistive index (RI) after extracorporeal shock wave lithotripsy (ESWL) in patients with non-obstructed kidney stones. Material and Method Between May 2020 and July 2021, 48 consecutive patients with unilateral renal calculi of  20 mm were treated with ESWL monotherapy. The patients' non-contrast computed tomography (NCCT) images were processed and grouped into two groups using Hounsfield units (HU) (Group 1, n=27,  1000 HU; Group 2, n=21,  1000 HU). The same radiologist performed Doppler ultrasonography on all cases before, one hour, and one week following ESWL. Measurement of the RI taken in the remote region (at least 20 mm from the stones). Patient age, gender, BMI, stone laterality, stone size, and stone position were investigated as potential predictors. Results The average stone size for Group 1 was 11.7 ± 3.3 mm and 12.1 ± 2.8 mm for Group 2. The mean RI values before ESWL for Group 1 and Group 2 were 0.54 and 0.53, respectively. On comparing the pre-treatment data with the 1 hour after SWL, a statistically significant increase was recorded in the RI value for both groups. However, there was no significant difference in RI values between groups 1 and 2 1 hour and 1 week following lithotripsy therapy. After one week, the mean RI returned to pretreatment levels, according to a follow-up doppler investigation. There was no association between stone density and RI (p > 0.05). Conclusion Stone density is a significant independent predictor of ESWL outcome; however, high stone densities detected with NCCT were not associated with a significant change in RI. Post-ESWL therapy alterations are present and reversible one week after the treatment.

Phloroglucinol-Derived Medications are Effective in Reducing Pain and Spasms of Urinary and Biliary Tracts: Results of Phase 3 Multicentre, Open-Label, Randomized, Comparative Studies of Clinical Effectiveness and Safety

INTRODUCTION

Pain and spasms of urinary and biliary tracts are conditions causing poor quality of life. Treatment with analgesic drugs such as non-steroidal anti-inflammatory drugs and modulators of the parasympathetic system are not always tolerated, and often additional therapeutic options are necessary. The present analysis aimed to evaluate the pharmacokinetics and effectiveness of oral and parenteral preparations based on phloroglucinol in reducing pain and spasms associated with renal or biliary colic in phase 3, multicentre, open-label, randomized, comparative studies on clinical effectiveness and safety.

METHODS

Pharmacokinetic and pharmacodynamic studies were carried out. Four phase 3 multicentre, open-label, randomized, comparative studies were conducted to evaluate the clinical effectiveness and safety in patients with pain and spasms of urinary or biliary tracts. Eligible patients randomly received either phloroglucinol orally or via intramuscular (IM)/intravenous (IV) administration and reference drug, dexketoprofen for urinary spasms and pain, the non-steroidal anti-inflammatory drug metamizole or scopolamine-based reference drug for biliary colic. The primary outcomes were symptoms and observed frequency of spasms, while the secondary outcome was the duration of improvement or the time between the drug administration and the recurrence of symptoms. Comparison of groups by quantitative characteristics was performed using the T-test for independent samples or the Mann-Whitney test. Intragroup comparisons were performed using the Wilcoxon test, or the T-test for linked samples. Qualitative signs were analysed using the Pearson's χ² test and Fisher's exact test.

RESULTS

The pharmacokinetic studies showed that (i) most of the phloroglucinol (> 80% for IV and per os formulations) was eliminated in the first 6 h after dosing, (ii) the drug was eliminated in urine as unchanged phloroglucinol (1,3,5-trihydroxybenzene) in a small proportion (< 3% of the dose) and (iii) a considerable amount of the drug was detected after enzymatic deconjugation with β-glucoronidase/arylsulfatase from Helix pomatia. As for the pharmacokinetic study, a total of 364 patients were enrolled, divided in four studies: two designed to test the effectiveness of oral and IM/IV preparations in biliary colic and two in urinary colic. Baseline characteristics between groups were similar. Phloroglucinol oral or IV/IM showed an effectiveness comparable to the reference drug in reducing pain and spasms associated with both urinary and biliary colic. There was no difference between all groups by survival analysis.

CONCLUSION

Oral and parenteral preparations based on phloroglucinol are as effective in reducing pain and spasms associated with renal or biliary colic as current therapeutic options. Therefore, phloroglucinol may be considered as useful to treat pain and spasms associated with urinary and biliary colic.

GeoBioMed perspectives on kidney stone recurrence from the reactive surface area of SWL-derived particles

Shock wave lithotripsy (SWL) is an effective and commonly applied clinical treatment for human kidney stones. Yet the success of SWL is counterbalanced by the risk of retained fragments causing recurrent stone formation, which may require retreatment. This study has applied GeoBioMed experimental and analytical approaches to determine the size frequency distribution, fracture patterns, and reactive surface area of SWL-derived particles within the context of their original crystal growth structure (crystalline architecture) as revealed by confocal autofluorescence (CAF) and super-resolution autofluorescence (SRAF) microscopy. Multiple calcium oxalate (CaOx) stones were removed from a Mayo Clinic patient using standard percutaneous nephrolithotomy (PCNL) and shock pulse lithotripsy (SPL). This produced approximately 4-12 mm-diameter PCNL-derived fragments that were experimentally treated ex vivo with SWL to form hundreds of smaller particles. Fractures propagated through the crystalline architecture of PCNL-derived fragments in a variety of geometric orientations to form rectangular, pointed, concentrically spalled, and irregular SWL-derived particles. Size frequency distributions ranged from fine silt (4-8 μm) to very fine pebbles (2-4 mm), according to the Wentworth grain size scale, with a mean size of fine sand (125-250 μm). Importantly, these SWL-derived particles are smaller than the 3-4 mm-diameter detection limit of clinical computed tomography (CT) techniques and can be retained on internal kidney membrane surfaces. This creates clinically undetectable crystallization seed points with extremely high reactive surface areas, which dramatically enhance the multiple events of crystallization and dissolution (diagenetic phase transitions) that may lead to the high rates of CaOx kidney stone recurrence after SWL treatment.

Multi-class motion-based semantic segmentation for ureteroscopy and laser lithotripsy

Ureteroscopy with laser lithotripsy has evolved as the most commonly used technique for the treatment of kidney stones. Automated segmentation of kidney stones and the laser fiber is an essential initial step to performing any automated quantitative analysis, particularly stone-size estimation, that can be used by the surgeon to decide if the stone requires further fragmentation. However, factors such as turbid fluid inside the cavity, specularities, motion blur due to kidney movements and camera motion, bleeding, and stone debris impact the quality of vision within the kidney, leading to extended operative times. To the best of our knowledge, this is the first attempt made towards multi-class segmentation in ureteroscopy and laser lithotripsy data. We propose an end-to-end convolution neural network (CNN) based learning framework for the segmentation of stones and laser fiber. The proposed approach utilizes two sub-networks: (I) HybResUNet, a hybrid version of residual U-Net, that uses residual connections in the encoder path of the U-Net to improve semantic predictions, and (II) a DVFNet that generates deformation vector field (DVF) predictions by leveraging motion differences between the adjacent video frames which is then used to prune the prediction maps. We also present ablation studies that combine different dilated convolutions, recurrent and residual connections, atrous spatial pyramid pooling, and attention gate models. Further, we propose a compound loss function that significantly boosts the segmentation performance in our data. We have also provided an ablation study to determine the optimal data augmentation strategy for our dataset. Our qualitative and quantitative results illustrate that our proposed method outperforms state-of-the-art methods such as UNet and DeepLabv3+ showing a DSC improvement of 4.15% and 13.34%, respectively, in our in vivo test dataset. We further show that our proposed model outperforms state-of-the-art methods on an unseen out-of-sample clinical dataset with a DSC improvement of 9.61%, 11%, and 5.24% over UNet, HybResUNet, and DeepLabv3+, respectively in the case of the stone class and an improvement of 31.79%, 22.15%, and 10.42% over UNet, HybResUNet, and DeepLabv3+, respectively, in case of the laser class.

Massive Ureterolithiasis

The authors present the case of a 40-year-old male who visited the emergency department with left-sided flank pain. He was found to have a 12 mm ureteropelvic stone and was provided parenteral analgesia before being admitted to the hospital for urology consultation. The presentation and diagnosis of his case along with treatment options against a backdrop of related studies are discussed.

Chemical Composition, Antioxidant Potentials, and Calcium Oxalate Anticrystallization Activity of Polyphenol and Saponin Fractions from Argania spinosa L. Press Cake

A wide range of biological properties and a potent therapeutic and prophylactic effect on chronic diseases are all present in Argania spinosa L. press cake. The aim of this research is to valorize the anticrystallization properties against calcium oxalate crystals of Argania spinosa L. press cake fractions and identify its bioactive components. Chemical species identification was performed using GC–MS analysis. The turbidimetric model was used to investigate crystallization inhibition in vitro. Infrared spectroscopy technique was used to characterize the synthesized crystals. Furthermore, both DPPH and FRAP methods were used to assess antioxidant activity. The results show that the fractions are equally important in crystallization inhibition percentages of calcium oxalate crystals. For saponin and polyphenol fractions, the inhibition percentages are in the orders of 83.49% and 82.83%, respectively. The results of the antioxidant activity by DPPH method show that the two fractions are equally important in the elimination of free radicals; the inhibition percentages were 77.87 ± 4.21 and 89.92 ± 1.39 for both polyphenols and saponins, respectively. FRAP method showed that the absorbance increases proportionally with concentration, and the absorbance are almost similar for both fractions and reach maximum values in the orders of 0.52 ± 0.07 and 0.42 ± 0.03, respectively, for saponins and polyphenols. These findings demonstrate that both fractions are rich in bioactive chemicals and have an anticrystallization capacity, allowing them to be employed for the curative and prophylactic effects against urolithiasis.

Role of Dual-Energy Computed Tomography in Urolithiasis

Objectives The objectives of this study are to describe the role of dual-energy computed tomography (DECT) in evaluation of renal stones in current practice and elaborate the imaging findings that need to be reported to help surgeons make an appropriate management strategy for renal stones.

Background Nephrolithiasis is a global problem, affecting people across geographical, cultural, and economic boundaries. Renal stones can be accurately diagnosed on computed tomography.

Discussion With the development of DECT, renal stones can now be better characterized in terms of stone burden, stone composition, and stone fragility.

Conclusion These parameters are helpful to treating surgeons in not only planning an appropriate management for patient but also in predicting the success of the various procedures such as extracorporeal shock wave lithotripsy, flexible ureterorenoscopy, or percutaneous nephrolithotomy. Familiarity with recent developments will help radiologists give an apt description of renal stone to meet the requirements of treating surgeon.

Chemical Composition and Anti-Urolithiatic Activity of Extracts from Argania spinosa (L.) Skeels Press-Cake and Acacia senegal (L.) Willd

Ethnobotanical studies have reported the traditional medicinal uses of Acacia senegal (L.) Willd. and Argania spinosa (L.) Skeels against kidney stone formation and other chronic kidney diseases. The present work is undertaken to study the litholytic activity and the inhibiting activity of calcium oxalate crystallization by bioactive compounds identified in Argania spinosa (L.) Skeels press-cake (residue of Argan oil) and in Acacia senegal (L.) Willd. The litholytic activity was studied in vitro on cystine and uric acid stones using a porous bag and an Erlenmeyer glass. The study of the inhibiting activity of calcium oxalate crystallization, was based on temporal measurements of the optical density, registered at a 620 nm wavelength for 30 min using an ultraviolet−visible spectrophotometer. The silylation method was performed to identify phytochemicals, followed by gas chromatography coupled with mass spectrophotometry (GC/MS) analysis. The results show significant litholytic activity of Argania Spinosa press-cake hydro-ethanolic extract on uric acid and cystine stones, respectively, with dissolution rates (DR) of 86.38% and 60.42% versus 3.23% and 9.48% for the hydro-ethanolic extract of Acacia senegal exudate. Furthermore, the percentages of nucleation inhibition are 83.78% and 43.77% (p ˂ 0.05) for Argania spinosa and Acacia senegal, respectively. The results point to the detection of 17 phytochemicals in Argania spinosa press-cake extract, the majority of which are phenolic acids and have potent anti-urolithiatic action.

Characterization of Acoustic, Cavitation, and Thermal Properties of Poly(vinyl alcohol) Hydrogels for Use as Therapeutic Ultrasound Tissue Mimics

The thermal and mechanical effects induced in tissue by ultrasound can be exploited for therapeutic applications. Tissue-mimicking materials (TMMs), reflecting different soft tissue properties, are required for experimental evaluation of therapeutic potential. In the study described here, poly(vinyl alcohol) (PVA) hydrogels were characterized. Hydrogels prepared using different concentrations (5%-20% w/w) and molecular weights of PVA ± cellulose scatterers (2.5%-10% w/w) were characterized acoustically (sound speed, attenuation) as a function of temperature (25°C-45°C), thermally (thermal conductivity, specific heat capacity) and in terms of their cavitation thresholds. Results were compared with measurements in fresh sheep tissue (kidney, liver, spleen). Sound speed depended most strongly on PVA concentration, and attenuation, on cellulose content. For the range of formulations investigated, the PVA gel acoustic properties (sound speed: 1532 ± 17 to 1590 ± 9 m/s, attenuation coefficient: 0.08 ± 0.01 to 0.37 ± 0.02 dB/cm) fell within those measured in fresh tissue. Cavitation thresholds for 10% PVA hydrogels (50% occurrence: 4.1-5.4 MPa, 75% occurrence: 5.4-8.2 MPa) decreased with increasing cellulose content. In summary, PVA cellulose composite hydrogels may be suitable mimics of acoustic, cavitation and thermal properties of soft tissue for a number of therapeutic ultrasound applications.

A single oscillating bubble in liquids with high Mach number

The oscillation characteristics of a single bubble and its induced radiation pressure and the dissipated power are essential for a wide range of applications. For bubble oscillations with high Mach number, the influence of the liquid compressibility is significantly strong and should be fully considered. In the present paper, the bubble wall motion equation with the second-order Mach number is employed for investigating a free oscillating bubble in the liquid with numerical and experimental verifications. For the purpose of comparisons, the revised Keller-Miksis equation up to the first-order Mach number is solved with the same conditions (e.g. the initial conditions and the ambient pressure). Through our simulations, comparing with the predictions by the first-order equation, we find that: (1) The bubble radius, the bubble wall radial velocity and the bubble wall radial acceleration predicted by the second-order equation with high Mach number are significantly different respectively, and the dimensionless differences increase with the increase of the Mach number. (2) The valid prediction range of the second-order equation is much larger. (3) The dissipated power predicted by the second-order equation with high Mach number is smaller.

Successful management of multiple obstructing renal calculi in a 30-year-old patient with autosomal dominant polycystic kidney disease using Frequency-Doubled Double-Pulse neodymium: Yttrium - Aluminium garnet laser lithotripsy

Autosomal dominant polycystic kidney disease (ADPKD) is the most prevalent genetic disorder that results in end-stage renal disease. Although ADPKD patients experience long disease trajectories, factors such as hypertension, proteinuria and renal calculi have been observed to lead to rapid renal function impairment in patients with ADPKD. Furthermore, due to the distorted anatomy that makes access to stone difficult, the management of nephrolithiasis in ADPKD patients is one of the several special situations in which urinary lithiasis presents management challenges. We report the case of a 30-year-old male with ADPKD and renal function impairment as a result of multiple obstructive calculi who was treated in Dialyser Medical Centre, Oshodi, Lagos, with Frequency-Doubled Double-Pulse Neodymium: Yttrium - Aluminium Garnet laser (FREDDY laser) lithotripsy, highlighting the possible advantage of FREDDY laser over other types of laser procedures given the minimal tissue-damaging potential of the laser type.

Bilateral same-session flexible ureteroscopy for renal stones: a feasible method

A staged ureteroscopic procedure is generally preferred to treat bilateral renal stones. In this study, we evaluated the feasibility of bilateral same-session flexible ureteroscopy (BS-fURS) in renal stones. A total of 81 patients underwent bilateral BS-fURS between March 2014 and March 2021 for bilateral renal stones. The mean stone burden per patient was 17±4 (range 7-27 mm). The average stone density was 1240 HU (970 to 1510). We used 4 types of ureteroscopes: Olympus URF-V2 (34 cases), Storz Flex X2 (30 cases), single-use PUSEN PU 3022 (12 cases), and single-use PUSEN - PU 3033A (5 cases). We specifically set our Holmium laser for dusting, pop-corning, and fragmenting. We found 31 calcium oxalate monohydrate cases, 11 calcium oxalate dehydrate cases, 17 uric acid cases, and 22 magnesium ammonium phosphate cases. The mean operating time was 77 min. (range 52 to 85) for both renal units. The SFRs were evaluated between 1 and 3 months with computed tomography (fragments >3 mm were defined as residual). Double J stenting (6Fr.) was applied bilaterally in 8 cases (9.87%) and unilateral in 34 cases (41.97%). The overall SFRs after 1 and 2 procedures were 81.48% (66/81 cases) and 92.59% (75/81 cases), respectively. Postoperative complications after an overall 96 procedures were Clavien I-II (18.75%) and Clavien III (3.12%). Urinary tract infections were observed in 13 cases (16.04%) without any case of urosepsis. Our experience suggested some BS-fURS advantages as a single anesthetic session and potentially reduced cost associated with treatment. BS-fURS seem feasible, especially for medium-sized bilateral renal stones in high-volume centers.

Systematic Review of the Prevalence of Kidney Stones in Cystic Fibrosis

Purpose: To investigate the prevalence of urolithiasis in cystic fibrosis (CF) and to summarize the available clinical features within this unique population. Methods: Studies reporting the prevalence of urolithiasis in CF patients were identified by a systematic search of the literature from inception to July 31, 2020 on three databases: Ovid Medline, Ovid Embase, and Web of Science. Data were extracted on a predetermined standardized form by two independent authors. Results: A total of 596 publications were retrieved and screened, 15 of which met the eligibility criteria. The publications were published between 1993 and 2019 and were all observational in design. There was a total of 2982 patients with CF included in this review. The overall prevalence of stone formation in the CF population was 4.6% (137/2982). The mean age of diagnosis was 25.1 ± 9.6 and ranged from 0.25 to 47. Ultrasound was the most common imaging modality for kidney stone diagnosis. There was no apparent sex difference, with a female to male ratio of 1:1. Surgical intervention was required in 37.8% (34/90) of cases. Stone recurrence was reported in 42.9% (33/77) of stone formers. Conclusions: This review provides the most recent update for the prevalence of urolithiasis in CF patients and summarizes the available clinical data. Our findings suggest that patients with CF could be at risk for developing stones at a younger age and require interventional management strategies at higher rates compared with the general population. Given the heterogeneity of the literature for urolithiasis in CF, larger population-based studies reporting the epidemiology, clinical features, and management strategies are required to further our understanding of urolithiasis in CF.

The role of intraoperative kidney mucosal biopsy on screening of squamous cell carcinoma of the kidney in nephrolithiasis patients with stones larger than 20 mm

Introduction:

Renal pelvic squamous cell carcinoma is a very rare tumor, with a prevalence <1% of all urinary tract tumors, about 0.5–8% of all kidney tumors, and the average age is 50–70 years. Although the incidence of renal squamous cell carcinoma is less common than renal cell carcinoma and renal transitional cell carcinoma, due to its more aggressive nature renal squamous cell carcinoma is often found intraoperatively and is already in an advanced stage or metastasis. The relevant medical history of squamous cell carcinoma is pyelonephritis, chronic nephrolithiasis, and a history of kidney stone surgery. Data which was obtained from previous research at Hasan Sadikin Hospital, from January 2014–December 2017, found the incidence of renal squamous cell carcinoma from nephrectomy procedures was 6%.

Methods:

This study was a cross-sectional study with a correlative analytic study, samples were taken consecutively from biopsy of kidney mucosa intraoperatively in hospitalized patients with kidney stones with size larger than 20 mm at the Department of Urology, Hasan Sadikin Hospital Bandung, which performed open kidney surgery or percutaneous nephrolithotomy from January–May 2019.

Results:

The number of samples in this study were from 30 patients, consisting of 16 males and 14 females. Five patients underwent open kidney surgery and 25 patients underwent percutaneous nephrolithotomy surgery, with an average of age of 49.5±11.8 years and 63.3% of patients were aged from 40–60 years. In this study, one patient (3.3%) showed squamous cell carcinoma of the kidney, a 57-year-old male patient with a left staghorn kidney stone who underwent left percutaneous nephrolithotomy surgery.

Conclusion:

There is a benefit for intraoperative kidney mucosal biopsy as a screening for squamous cell carcinoma of the kidney in nephrolithiasis patients with stones larger than 20 mm.

Level of evidence:

3

The relationship between the stone-free status after extracorporeal shockwave lithotripsy (ESWL) treatment in different patient and kidney stone characteristics: A single center experience in Saudi Arabia

Purpose:

The objective was to unveil the relationship between different relevant patient and kidney stone characteristics and the stone-free status post extracorporeal shockwave lithotripsy (ESWL) treatment.

Materials and methods:

Kidney stones cases referred for ESWL from October 2019 to January 2020 were collected. A total of 225 adult patients who met the criteria of being new cases of single radio-opaque kidney stones measuring 5 to 20 mm were included. We were looking for disintegrated stones down to 4 mm or less as a marker for stone-free (SF) status. The studied parameters were gender, laterality (right or left kidney), location of the stone within the kidney, stone’s density measured in Hounsfield units (HU), stone’s size, and stone-to-skin distance (SSD).

Results:

Out of the 225 cases treated, only 175 (77.8%) became SF after or during the study timeframe. SF status was achieved after the first session in 131 cases (58.2%). The bivariate analysis of the factors associated with higher SF rates found to be statistically significant were left kidney ( p-value of < 0.01), low stone density ( p-value of < 0.01), short stone–skin distance ( p-value of < 0.01), and small stone size ( p-value of < 0.01). On the other hand, gender and stone location within the kidney showed no association with ESWL outcomes.

Conclusion:

Kidney laterality, SSD, stone density, and size are influencing parameters on ESWL outcomes and achievement of stone-free status.

Efficacy and safety of laparoscopic pyelolithotomy versus percutaneous nephrolithotomy for treatment of large renal stones: a meta-analysis

Background

We aimed to compare the efficacy and safety of laparoscopic pyelolithotomy (LPL) versus percutaneous nephrolithotomy (PCNL) for treating renal stones larger than 2 cm.

Methods

We searched the PubMed, Embase, Web of Science, SinoMed, and Chinese National Knowledge Infrastructure databases for studies that compared the surgical outcomes of LPL and PCNL. We conducted a meta-analysis of the retrieved studies, expressed as weighted mean difference or risk ratios with 95% confidence intervals.

Results

We included 25 studies (1831 patients). LPL was associated with a significantly higher stone-free rate, lower rates of blood loss, complementary treatment, blood transfusion, and complications, and less reduction in hemoglobin level compared with PCNL. LPL and PCNL were similar in terms of duration of hospital stay, conversion rate, changes in glomerular filtration rate and creatinine level, and mean time of postoperative analgesia. However, LPL was associated with a longer operation time than PCNL.

Conclusion

LPL appears to be more effective and safer than PCNL in patients with large renal stones, by increasing the stone-free rate and reducing blood loss, complementary treatment, blood transfusion, and complications compared with PCNL. LPL may thus be a useful modality for treating patients with large renal stones.

Prediction of burden and management of renal calculi from whole kidney radiomics: a multicenter study

Purpose

To assess if autosegmentation-assisted radiomics can predict disease burden, hydronephrosis, and treatment strategies in patients with renal calculi.

Methods

The local ethical committee-approved, retrospective study included 202 adult patients (mean age: 53 ± 17 years; male: 103; female: 99) who underwent clinically indicated, non-contrast abdomen-pelvis CT for suspected or known renal calculi. All CT examinations were reviewed to determine the presence (n = 123 patients) or absence (n = 79) of renal calculi. On CT images with renal calculi, each kidney stone was annotated and measured (maximum dimension, Hounsfield unit (HU), and combined and dominant stone volumes) using a HU threshold-based segmentation. We recorded the presence of hydronephrosis, number of renal calculi, and treatment strategies. Deidentified CT images were processed with the radiomics prototype (Radiomics, Frontier, Siemens Healthineers), which automatically segmented each kidney to obtain 1690 first-, shape-, and higher-order radiomics. Data were analyzed using multiple logistic regression analysis with areas under the curve (AUC) as output.

Results

Among 202 patients, only 28 patients (18%) needed procedural treatment (lithotripsy or ureteroscopic stone extraction). Gray-level co-occurrence matrix (GLCM) and gray-level run length matrix (GLRLM) differentiated patients with and without procedural treatment (AUC 0.91, 95% CI 0.85–0.92). Higher-order radiomics (gray-level size zone matrix – GLSZM) differentiated kidneys with and without hydronephrosis (AUC: 0.99, p < 0.001) as well those with different stone volumes (AUC up to 0.89, 95% CI 0.89–0.92).

Conclusion

Automated segmentation and radiomics of entire kidneys can assess hydronephrosis presence, stone burden, and treatment strategies for renal calculi with AUCs > 0.85.

Factors influencing extracorporeal shock wave lithotripsy efficiency for optimal patient selection

Introduction

Current literature suggests various predictors related to the stone and patient, which could influence stone fragmentation and clearance rates.

Aim

To establish clinical characteristics of stone disease for patients undergoing extracorporeal shockwave lithotripsy (ESWL) which may predict the success of the procedure.

Material and methods

One hundred and nine patients with renal stone disease diagnosed by non-contrast computed tomography (NCCT) who underwent ESWL between January 2015 and December 2019 were included in the study. Endpoints: patient being stone free (SF) or when < 4 mm fragments were detected. Age, gender, location, skin-to-stone distance, maximum stone length, stone volume, stone surface area, mean stone Hounsfield units (HU) and highest HU score were explored in uni- and multivariate regression analysis.

Results

Stone size revealed the highest prognostic power for ESWL failure, where OR for stone volume and stone surface area were 1.06 (1.03–1.10) and 1.04 (1.02–1.06), respectively (all p < 0.01) while a tendency was observed for skin-to-stone distance 1.02 (1.00–1.03). The amount of energy applied during the procedure to one cubic millimeter of stone volume (SMLI/stone volume) was predictive for treatment success (OR = 0.60, 95% CI: 0.41–0.87, p < 0.01). Stone volume (OR = 1.06, 95% CI: 1.00–1.14, p = 0.01) and stone surface area (OR = 1.03, 95% CI: 1.01–1.06, p = 0.02) remained as statistically significant prognostic factors for treatment failure.

Conclusions

Both greater stone volume and stone surface area, as well as lower power delivered per stone volume unit during the ESWL procedure, were found to be significant factors and could be useful to predict treatment failure.

Incidence of kidney stones in pregnancy and associations with adverse obstetrical outcomes: a systematic review and meta-analysis of 4.7 million pregnancies

BACKGROUND

Renal stones are a common cause of non-obstetrical abdominal pain in pregnant women. Though the management of renal stones in pregnancy is challenging, it remains unclear how the incidence of kidney stones may affect the course of pregnancy and delivery.

OBJECTIVE

To determine the incidence of renal stones in pregnancy and its impact on adverse obstetrical outcomes.

DATA SOURCES

We conducted a systematic literature search of three databases: Ovid MEDLINE, Ovid EMBASE, and EBSCO CINAHL Plus. After the selection of articles, an additional hand-search of their citations was completed to maximize sensitivity. Databases were examined from the last four decades (19 March 1970) up to the search date (19 March 2020).

STUDY ELIGIBILITY CRITERIA

Articles were excluded if they were not relevant to kidney stones or did not report outcomes related to pregnancy. Case reports, animal studies, and cadaveric studies were excluded. Conference abstracts, gray literature, and unpublished data were not eligible.

STUDY APPRAISAL AND SYNTHESIS METHODS

All screening, extraction, and synthesis were completed in duplicate with two independent reviewers. All outcomes reported in the included studies were systematically evaluated to determine suitability for meta-analysis. Random-effects models and sensitivity analyses were used to account for interstudy variation. Renal stone incidence rates were pooled to generate summary proportions. Risk of bias assessment was completed using the Risk of Bias Assessment tool for Non-randomized Studies.

RESULTS

Twenty-one studies were included through systematic review and approximately 4.7 million pregnancies across nine studies were included for meta-analysis. There are three major findings of this review regarding renal stone incidence in pregnancy and maternal, child, and birth-related outcomes associated with renal stones. First, we found pooled incidence of renal stones was 0.49%, or one case for every 204 pregnancies. Second, renal stones during pregnancy were significantly associated with the development of preeclampsia and urinary tract infection, as well as increased likelihood of low birth weight, preterm labor, and C-section deliveries. However, renal stones were not significantly associated with premature rupture of membranes or infant mortality. Third, there were limited obstetrical complications reported with either medical or surgical therapies although comparative outcomes were not provided in the majority of studies, precluding formal meta-analysis.

CONCLUSIONS

Although renal stones in pregnancy are relatively rare, there may be an associated risk of serious adverse obstetrical outcomes. However, further research is required to understand whether these obstetrical outcomes are causal or due to other confounders. Interdisciplinary care and pregnancy-specific counseling should be advised for pregnant women with kidney stones.

Reported and Unreported Potentially Important Incidental Findings in Urgent Nonenhanced Abdominal CT for Renal Colic

OBJECTIVE

The aim of the study was to retrospectively evaluate the prevalence of reported and unreported potentially important incidental findings (PIFs) in consecutive nonenhanced abdominal CTs performed specifically for renal colic in the urgent setting.

METHODS

One radiologist, blinded to the finalized report, retrospectively re-evaluated nonenhanced abdominal CTs performed from January to December 2017 on adult patients from the emergency department with the specific request of urgent evaluation for renal colic, searching for PIFs.

RESULTS

The CTs of 312 patients were included in the study. Thirty-eight findings were reported in 38 different CTs, whereas the re-evaluation added 47 unreported findings in 47 different CTs, adding to total of 85 findings (27%). The difference in the proportion of reported and unreported PIFs between the original report and re-evaluation was significant (p < 0.001). No significant difference was found between the age of patients with and without reported findings. The proportion of potentially important findings did not vary significantly among the 3 shifts in the original report and in re-evaluation. The most frequent findings, both reported and unreported, were pleural effusion, lymphadenopathies, and liver nodules.

CONCLUSIONS

Potentially important additional findings are frequently present in urgent nonenhanced abdominal CTs performed for renal colic, and many are not described in the finalized reports. Radiologists should take care not to underreport PIFs even in the urgent setting because of the possible consequences on the patient's health and in order to avoid legal issues, while at the same time satisfying the need for timely and efficient reporting.

Evaluation of the effect of Moringa peregrina bark on the crystal habit and size of calcium oxalate monohydrate crystals in different stages of crystallization using experimental and theoretical methods

Moringa peregrina bark extract is found to successfully retard the nucleation and aggregation of calcium oxalate monohydrate crystals and distort their shape, a mechanism for which is proposed using molecular modeling.

Complications in Patients With Autosomal Dominant Polycystic Kidney Disease Undergoing Ureteroscopy: A Cohort Study

BACKGROUND

Ureteroscopy is a minimally invasive treatment option for upper tract stones. The distorted kidney anatomy in patients with autosomal dominant polycystic kidney disease (ADPKD) may place them at higher risk for ureteroscopic complications.

OBJECTIVE

To compare the 30-day risk of ureteroscopic complications between patients with and without ADPKD.

DESIGN

Retrospective cohort study.

SETTING

Ontario, Canada.

PATIENTS

Seventy three patients with ADPKD and 81 445 patients without ADPKD who underwent ureteroscopy for upper urinary tract stones between April 1, 2002, and March 1, 2018.

MEASUREMENTS

A 30-day risk of (1) hospital presentation with ureteroscopic complications (which was a composite outcome of either emergency department visit or hospital admission with acute kidney injury, urinary tract infection, or sepsis); (2) all-cause hospital presentation; (3) all-cause hospital admission; and (4) all-cause emergency department visit.

METHODS

We regressed outcomes on demographic variables, health care use in the prior 1-year, various procedures and comorbidities related to the outcome in the prior 5 years, and prescribed medications filled in the past 120 days using modified Poisson regression to compare the risk ratio (RR) of each outcome between patients with and without ADPKD.

RESULTS

The median (interquartile, IQR) age was 44 (38-60 years) in the ADPKD group and 53 (42-64) in the control group. About 40% were women in both groups. The risk of ureteroscopic complications was not significantly different in patients with versus without ADPKD (8.2% vs 4.3%; adjusted RR = 1.5, 95% confidence interval [CI] = 0.7-3.2). Patients with versus without ADPKD were more likely to present to hospital after their procedure (35.6% vs. 20.0%; adjusted RR = 1.6, 95% CI = 1.2-2.2), which included a statistically significant increase in the risk of presenting to the emergency department (32.9% vs. 19.0%; adjusted RR = 1.6, 95% CI = 1.1-2.2) but not hospital admissions (10.9% vs. 5.0%; adjusted RR = 1.8, 95% CI = 0.9-3.4).

LIMITATIONS

The low numbers of events led to imprecision around the estimates.

CONCLUSION

Patients with ADPKD have a higher risk of return to the hospital within 30 days of ureteroscopy for stone disease.

TRIAL REGISTRATION

We did not register this study.

Efficacy and Safety of External Physical Vibration Lithecbole After Extracorporeal Shock Wave Lithotripsy or Retrograde Intrarenal Surgery for Urinary Stone: A Systematic Review and Meta-analysis

Introduction: The current study evaluated the efficacy and safety of external physical vibration lithecbole (EPVL) after extracorporeal shock wave lithotripsy (SWL) or retrograde intrarenal surgery (RIRS) for urolithiasis. Methods: Publicized literature was systematically searched from EMBASE, Cochrane Library, PubMed, ScienceDirect, ClinicalTrials.gov, and Web of Science up to February 2020. Fixed-effects or random-effects model was chosen in risk ratio (RR) calculation according to heterogeneity. Quality of evidence was estimated under the guidance of Cochrane handbook. Stone expulsion rate, stone-free rates (SFRs), and complication rates were set as end points. Results: Six randomized controlled trials, including 853 patients, were eligible for analysis. EPVL significantly increased SFR within 3 weeks (RR = 1.17, 95% CI: 1.06-1.29, P = 0.001) and above 3 weeks (RR = 1.19, 95% CI: 1.03-1.37, P = 0.02) after SWL. EPVL also improved SFR within 3 weeks (RR = 1.84, 95% CI: 1.35-2.49, P < 0.0001) and above 3 weeks (RR = 1.53, 95% CI: 1.33-1.77, P < 0.00001) after RIRS. Besides, EPVL can significantly increase SFRs for stones in renal pelvis, lower calix, and multiple locations (all P-value <0.05). Although the overall complication rate was not significantly higher in EPVL + RIRS group, it was found to be 1.38 times higher in EPVL+SWL group (RR = 1.38, 95% CI: 1.06-1.79, P = 0.02), especially the incidence of flank pain (RR = 3.11, 95% CI: 1.02-9.46, P = 0.05). Conclusions: EPVL is effective and safe with high SFRs (especially in renal pelvis, lower calix, and multiple locations) after SWL or RIRS and lower overall complication rate after RIRS in patients with urolithiasis. However, the overall complication rate (especially the incidence of flank pain) was higher after EPVL + SWL.

Usability of shear wave elastography to predict the success of extracorporeal shock-wave lithotripsy: prospective pilot study

The present study is intended to investigate the usability of shear wave elastography (SWE) in predicting the success of extracorporeal shock-wave lithotripsy (ESWL) used in kidney stone treatment. ESWL was performed on a total number of 52 patients diagnosed with kidney stones between May 2019 and July 2020. The presence of a residual stone greater than 4 mm was accepted as failure. The patients were divided into two groups as ESWL success and ESWL failure. SWE and Hounsfield unit (HU) measurements of stones were performed in all patients before ESWL. The two groups were compared in terms of age, gender, stone localisation, stone size, body mass index (BMI), skin-to-stone distance, HU, and SWE values of the stones. ESWL was successful in 30 of the 52 patients included in the study, while it failed in 22 of them. While the mean SWE value was 7.3 (7.9 ± 2.2) kPa in patients with success in ESWL, it was 14.6 (17.9 ± 10.2) kPa in those with failed ESWL. The mean HU was 883.5 (841.4 ± 191.1) in patients with success in ESWL and 1078 (1115.5 ± 183) in those with failed ESWL. Both SWE and HU values of the stones were found to be statistically significantly lower in the successful group (p < 0.05). It was seen that SWE and HU values were correlated to each other. The groups of successful and failed ESWL did not differ significantly in terms of age, gender distribution, stone size, BMI, and skin-to-stone distance (p > 0.05). With SWE, the hardness of the stone can be measured and its suitability for ESWL can be evaluated. It can be used as an alternative parameter to HU before ESWL treatment, since it has a lower cost compared to computed tomography (CT) and does not contain radiation.

Human kidney stone matrix proteins alleviate hyperoxaluria induced renal stress by targeting cell-crystal interactions

Increased levels of urinary oxalate also known as hyperoxaluria, increase the likelihood of kidney stone formation through enhanced calcium oxalate (CaOx) crystallization. The management of lithiatic renal pathology requires investigations at the initial macromolecular stages. Hence, the current study was designed to unravel the protein make-up of human kidney stones and its impact on renal cells' altered proteome, induced as the consequence of CaOx injury. CaOx kidney stones were collected from patients; stones were pooled for entire cohort, followed by protein extraction. Immunocytochemistry, RT-PCR and flow-cytometric analysis revealed the promising antilithiatic activity of kidney stone matrix proteins. The iTRAQ analysis of renal cells showed up-regulation of 12 proteins and down-regulation of 41 proteins due to CaOx insult, however, this differential expression was normalized in the presence of kidney stone matrix proteins. Protein network analysis revealed involvement of up-regulated proteins in apoptosis, calcium-binding, inflammatory and stress response pathways. Moreover, seven novel antilithiatic proteins were identified from human kidney stones' matrix: Tenascin-X-isoform2, CCDC-144A, LIM domain kinase-1, Serine/Arginine receptor matrix protein-2, mitochondrial peptide methionine sulfoxide reductase, volume-regulated anion channel subunit-LRRC8A and BMPR2. In silico analysis concluded that these proteins exert antilithiatic potential through crystal binding, thereby inhibiting the crystal-cell interaction, a pre-requisite to initiate inflammatory response. Thus, the outcomes of this study provide insights into the molecular events of CaOx induced renal toxicity and subsequent progression into nephrolithiasis.

Early experience of Retrograde Intrarenal Surgery for Renal stone: A Descriptive Cross-sectional Study

Introduction:

Retrograde intrarenal surgery with improving skill and knowledge may be considered one of the first-line treatment options for removal of renal stones. The study is done to find the outcome of retrograde intrarenal surgery (RIRS) in patients with renal stone.

Method:

This descriptive cross sectional study was carried out on patients undergoing retrograde intrarenal surgery for renal stone at a tertiary care hospital December 2019 to March 2020. Ethical approval was taken from the institutional review committee (Ref. no.200120202). The Convenient sampling method was applied. Data was collected and analyzed in Statistical Package for the Social Sciences version 20.0. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data.

Results:

Out of the 28 patients, the retrograde intrarenal surgery was successful in 27 (96.4%) cases. There were 16 (57.15%) females and 12 (42.86%) male patients with the mean age of 37.86±11.47 years. Most of the stones were in renal pelvis 18 (64.28%) followed by lower calyx 8(28.57%). The mean diameter of the stone was 11.47±3.33mm whereas most of the stones were on the right side 16 (57.15%). The mean hardness was 1155.21±265.34 Hounsfield units. Perioperative complications like failed access sheath placement in 2 (7.14%) cases, hematuria in 6 (21.43%) cases, fever in 6 (21.43%) cases, and septicemia in 4 (14.28%) cases.

Conclusions:

We found that the success rate of retrograde intrarenal surgery for the renal stone was acceptable and similar to other published studies . Retrograde intrarenal surgery is feasible for the treatment of kidney stones with acceptable complications and success rates.

Efficacy and Safety of Surgical Kidney Stone Interventions in Autosomal Dominant Polycystic Kidney Disease: A Systematic Review

BACKGROUND

Reduced kidney function and distorted kidney anatomy in patients with autosomal dominant polycystic kidney disease (ADPKD) may complicate stone interventions more compared with the general population.

OBJECTIVES

To review studies describing the safety and efficacy of the 3 main stone interventions in adults with ADPKD: shock wave lithotripsy (SWL), ureteroscopy, and percutaneous nephrolithotomy (PCNL).

DESIGN

Systematic review.

SETTING

Any country of origin.

PATIENTS

Adults with ADPKD who underwent SWL, ureteroscopy, or PCNL.

MEASUREMENTS

Being stone free after the intervention and postoperative complications as reported by each study, which included pain, bleeding, and fever.

METHODS

Relevant studies published until February 2019 were identified through a comprehensive search of MEDLINE, EMBASE, Web of Science, BIOSIS PREVIEW, and CINAHL. Studies were eligible for review if they reported at least one outcome following SWL, ureteroscopy, and/or PCNL in adults with ADPKD. We then abstracted information on study characteristics, patient characteristics, intervention details, and postintervention outcomes and assessed the methodological quality of each study using a modified Downs and Black checklist.

RESULTS

We screened 221 citations from which we identified 24 studies that met our review criteria. We identified an additional article when manually reviewing the reference list of an included article, yielding a total of 25 studies describing 311 patients (32 SWL, 42 ureteroscopy, and 237 PCNL). The percentage of patients who were stone free after 1 session ranged from 0% to 69% after SWL, 73% to 100% after ureteroscopy, and 45% to 100% after PCNL. The percentage of patients with ADPKD that experienced at least one postoperative complication ranged from 0% to 33% for SWL, 0% to 27% for ureteroscopy, and 0% to 100% for PCNL.

LIMITATIONS

The number and quality of studies published to date are limited.

CONCLUSIONS

The efficacy and safety of stone interventions in patients with ADPKD remains uncertain, with wide-ranging estimates reported in the literature.

TRIAL REGISTRATION

We did not register the protocol of this systematic review.

Prediction of stone-free rates following extracorporeal shockwave lithotripsy in a contemporary cohort of patients with stone densities exceeding 1000 HU

Purpose: Nephrolithiasis is a common urologic problem, and its incidence is increasing. Shockwave Lithotripsy (SWL) has better results for patients with stones < 1000 HU. We attempted to identify SWL stone-free (SF) predictors for > 1000 HU stones.Methods: From January 2013 to September 2019, patient shared decision consecutive SWL for the treatment of a single > 1000 HU renal stone diagnosed by non-contrast computed tomography (NCCT). Endpoints: Fragmentation and SF or clinically insignificant residual fragments ≤ 4 mm at 4 weeks. Age, gender, stone side, location, size and density, number and average energy (Joules) of shocks were explored on uni- and multivariate regression analysis.Results: All sixty-one patients included were diagnosed with renal stone between 5 and 20 mm (maximum length) and underwent one SWL session only: 62.3% males, median age 48 (21-80) years, mean stone size 9.43 ± 2.9 mm (6.0-20.0), mean density 1210 ± 135 HU (1000-1558). There were 39 (63.9%) cases of SF, 16 (26.2%) of partial success and six (9.8%) of no success. Stone size was the only independent predictor of fragmentation, OR = 1.83, 95% CI = 1.32-2.55, p = 0.0003, and SF OR = 1.91, 95% CI = 1.31-2.78, p = 0.008. The best discriminatory stone size on ROC analysis was 1 cm.Conclusion: Stone size was the only significant success predictor in our cohort, with 76% SF rate for stones < 1 cm in 4 weeks follow-up, supporting that renal stones > 1000 HU may be suitable to SWL.

Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: A randomized controlled trial

OBJECTIVES

We aimed to evaluate the efficacy of intracutaneous sterile water injection (ISWI) to relieve the pain of acute renal colic compared with diclofenac and placebo.

METHODS

The study included 150 patients presented to the Emergency Department with renal colic randomized into 3 groups: control group received intracutaneous injections of 0.5 cm³ isotonic saline in the flank, group A received intracutaneous injections of 0.5 cm³ ISWI in the flank, and group B received an intramuscular injection of 75 mg Diclofenac in the gluteal region. The severity of the pain was assessed by a visual analogue scale system at baseline and 30, 45 min, and 60 min after injections. Subjects with inadequate pain relief at 1 h received rescue analgesia.

RESULTS

The mean baseline pain score was 9.6 ± 0.61 in the ISWI group, 9.72 ± 0.64 in the diclofenac group and 9.26 ± 0.89 in the control group. The mean pain score at 30 min of the control group was reduced to 6.9 ± 1.56. This mean at 30 min after ISWI and diclofenac injections were reduced to 1.98 ± 1.41 and 1.88 ± 1.19 respectively. The mean of pain sore of the ISWI and diclofenac group at 45 and 60 min was constant. Rescue analgesics at 1 h were required by 47 patients receiving the saline injection and by 4 patients and by 7 patients receiving ISWI and diclofenac injection respectively.

CONCLUSIONS

ISWI and diclofenac were equally effective for the pain relief of acute renal colic.

Genetic and Clinical Analyses of 13 Chinese Families With Cystine Urolithiasis and Identification of 15 Novel Pathogenic Variants in SLC3A1 and SLC7A9

Background

Cystinuria is a rare genetic disorder characterized by defective renal reabsorption of cystine, ornithine, arginine, and lysine. The increased urinary excretion of cystine results in the development of cystine urolithiasis (CU). The mutated SLC3A1 and SLC7A9 genes are the cause of CU, a global disorder. Its frequency and mutation spectrum vary between different populations. In Asia, the data for CU are limited.

Method

Urinary stones were collected from patients of a single center over a five-year period and analyzed via Fourier transform infrared spectroscopy. Genomic DNA was isolated from 13 patients with CU and their parents and from 26 controls affected by calcium oxalate dihydrate stones. The coding regions and the exon-intron boundaries of SLC3A1 and SLC7A9 were subjected to PCR amplification and then sequenced via traditional Sanger sequencing. Genetic variants were functionally annotated using the InterVar, ClinVar, gnom AD, and HGMD databases.

Results

From the 232 samples of urinary stones, we identified 13 patients with CU (10 males and 3 females). The onset age was from 7 months to 9 years. The CU stones varied from 0.26 cm³ to 18.67 cm³. Sanger sequencing detected a total of 14 SLC3A1 (nine were novel) and 10 SLC7A9 (six were novel) rare variants from the 13 CU families. All variants, including 15 novel variants, were pathogenic, disease-causing, or damaging.

Conclusion

All 13 pediatric CU families harbored SLC3A1 or/and SLC7A9 rare variants. A total of 15 novel pathogenic variants in SLC3A1 and SLC7A9 were identified. This study expanded the known mutational spectrum of CU in the Chinese population.

Spontaneous rupture of the renal calyx secondary to a vesicoureteral junction calculus

BACKGROUND

Spontaneous urinary collecting system rupture is caused by increased ureteral intraluminal pressure secondary to an obstruction. Rarely, a small stone exerts high intraureteral pressure especially if it is located distally. Many management modalities with good outcomes have been implicated.

PURPOSE

Herein, we present a case of nontraumatic rupture of the renal calyx due to a 4 mm obstructing stone at the vesicoureteral junction.

BASIC PROCEDURES

CT scan of abdomen and pelvis without contrast, CT scan of the abdomen and pelvis with intravenous contrast, Cystoscopy, Double-J ureter stent, Urinary Foley catheter.

MAIN FINDINGS

The diagnosis was confirmed by CT imaging. Non-contrast enhanced CT scan of abdomen and pelvis showed obstructive calculi measuring 4 mm in the right vesicoureteral junction. Contrast-enhanced CT scan revealed leakage of contrast in the perinephric space at the right major calyx with intact bilateral ureters, suggestive of calyceal rupture. The treatment involved antibiotics and double-J stenting.

PRINCIPAL CONCLUSIONS

This case demonstrates that spontaneous calyceal rupture should be suspected in urolothiasis patients presenting for a severe pain even if the calculus is small (less than 5 mm) and the laboratory markers are normal. An immediate management is required to relief symptoms and prevent further complications.

Tubeless supra-costal percutaneous nephrolithotomy is associated with significantly less hydrothorax: a prospective randomized clinical study

OBJECTIVES

To evaluate prospectively whether a tubeless (JJ stent-only) percutaneous nephrolithotomy (PCNL) might reduce the risk of hydrothorax, compared to an approach where a nephrostomy tube is left.

MATERIALS AND METHODS

We conducted a two-arm open-label prospective randomized study (NCT02036398) comparing tubeless supra-costal PCNL (with a JJ stent only) to standard PCNL (with nephrostomy tube and JJ stent) using intention-to-treat (ITT) and per-protocol (PP) analyses. All patients underwent a standard single-stage prone supra-costal procedure with single-tract access. Complication data were collected according to the Clavien-Dindo grading system. The primary endpoint was the rate of hydrothorax, and secondary endpoints included stone-free rate (SFR) and complication rate. Multivariable logistic regression analysis identified factors associated with hydrothorax formation.

RESULTS

Out of 101 patients approached, 75 were finally analysed. No differences were observed between the two arms with regard to baseline demographic and stone characteristics. The mean largest stone size ranged between 23 and 24.2 mm. No significant difference was seen in the mean operating time and length of hospital stay. The incidence of hydrothorax was significantly higher in the nephrostomy group in comparison to the tubeless group (37.8% vs 15.8%, P = 0.031, and 38.4% vs 13.8%, P = 0.016, in the ITT and PP analyses, respectively). The SFR and complication rate were similar in both groups using the ITT and PP analyses. Multivariable logistic regression analysis showed that nephrostomy tube placement was the only covariate associated in a statistically significant manner to hydrothorax (odds ratio 3.628, 95% confidence interval 1.073-12.265; P = 0.038).

CONCLUSION

The rate of hydrothorax in supra-costal PCNL is associated with the type of postoperative drainage left. When possible, a tubeless approach should be applied as it may confer a lower risk of hydrothorax.

Effect of JJ stent on outcomes of extracorporeal shock wave lithotripsy treatment of moderate sized renal pelvic stones: A randomized prospective study

PURPOSE

To evaluate the effect of JJ stents on SWL treatment of moderate (15-25mm) renal pelvic stones.

MATERIALS AND METHODS

Between January 2016 and December 2017, a total of 152 adult patients who were planned to undergo SWL for a single radiopaque renal pelvic stone were included in the study. Patients with solitary kidney, congenital abnormality, skeletal tract abnormalities, previous urinary system surgery, hydronephrosis (grade 2 or more), untreated urinary tract infection, bleeding disorder, and suspected pregnancy were excluded. The remaining 114 patients were randomly divided into two groups; non-stented and stented. Twenty-two patients whose stone could not be fragmented despite 3 consecutive sessions were also excluded from the study. A total of 92 patients (54 non-stented and 38 stented) were included in the final analysis.

RESULTS

There was no significant difference in terms of age, sex, body mass index, renal parancyhimal thickness, hydronephrosis, skin-to-stone distance, Hounsfield units, and stone size between the groups. Success was significantly higher in the stented group than in the non-stented group (71% vs. 39%, P=.002). In stone-free patients, the number of emergency department visits and analgesic tablet consumption was significantly lower in the stented group than in the non-stented group (P<.001 and P<.001, respectively). In non- stone-free patients, analgesic tablet consumption was significantly lower in the stented group than in the non-stented group (P=.004).

CONCLUSIONS

Pre-stenting before SWL treatment of moderate sized renal pelvic stones has some advantages in terms of success, emergency service visits, and analgesic tablet consumption.

Transmuscular quadratus lumborum block for percutaneous nephrolithotomy reduces opioid consumption and speeds ambulation and discharge from hospital: a single centre randomised controlled trial

BACKGROUND

Percutaneous nephrolithotomy (PNL) is associated with severe postoperative pain. The current study aimed to investigate the analgesic efficacy of transmuscular quadratus lumborum (TQL) block for patients undergoing PNL surgery.

METHODS

Sixty patients were enrolled in this single centre study. The multimodal analgesic regime consisted of oral paracetamol 1 g and i.v. dexamethasone 4 mg before surgery and i.v. sufentanil 0.25 μg kg-1 30 min before emergence. After operation, patients received paracetamol 1 g regularly at 6 h intervals. Subjects were allocated to receive a preoperative TQL block with either ropivacaine 0.75%, 30 ml (intervention) or saline 30 ml (control). Primary outcome was oral morphine equivalent (OME) consumption 0-6 h after surgery. Secondary outcomes were OME consumption up to 24 h, pain scores, time to first opioid, time to first ambulation, and hospital length of stay. Results were reported as mean (standard deviation) or median (inter-quartile range).

RESULTS

Morphine consumption was lower in the intervention group at 6 h after surgery (7.2 [8.7] vs 90.6 [69.9] mg OME, P<0.001) and at 24 h (54.0 [36.7] vs 126.2 [85.5] mg OME, P<0.001). Time to first opioid use was prolonged in the intervention group (678 [285-1020] vs 36 [19-55] min, P<0.0001). Both the time to ambulation (302 [238-475] vs 595 [345-925] min, P<0.004) and length of stay (2.0 [0.8] vs 3.0 [1.2] days, P≤0.001) were shorter in the intervention group.

CONCLUSIONS

This is the first blinded, RCT that confirms that unilateral TQL block reduces postoperative opioid consumption and hospital length of stay. Further study is required for confirmation and dose optimisation.

CLINICAL TRIAL REGISTRATION

NCT02818140.

Low-dose intravenous ketamine versus intravenous ketorolac in pain control in patients with acute renal colic in an emergency setting: a double-blind randomized clinical trial

BACKGROUND

This study was conducted to compare the effectiveness of low-dose ketamine versus ketorolac in pain control in patients with acute renal colic presenting to the emergency department (ED).

METHODS

This is a double-blind randomized clinical trial. The initial pain severity was assessed using the numerical rating scale (NRS). Then, ketamine or ketorolac was administered intravenously at a dose of 0.6 mg/kg and 30 mg respectively. The pain severity and adverse drug reactions were recorded 5, 15, 30, 60, and 120 min thereafter.

RESULTS

The data of 62 subjects in the ketamine group and 64 patients in the ketorolac group were analyzed. The mean age of the patients was 34.2 ± 9.9 and 37.9 ± 10.6 years in the ketamine and ketorolac group, respectively. There was no significant difference in the mean NRS scores at each time point, except for the 5 min, between the two groups. Despite a marked decrease in pain severity in the ketamine group from drug administration at the 5 min, a slight increase in pain was observed from the 5 min to the 15 min. The rate of adverse drug reactions, including dizziness (P = 0.001), agitation (P = 0.002), increased systolic blood pressure (> 140 mmHg), and diastolic blood pressure (> 90 mmHg) was higher in the ketamine group.

CONCLUSIONS

Low dose ketamine is as effective as ketorolac in pain management in patients with renal colic presenting to the ED. However, it is associated with a higher rate of adverse drug reactions.