Surgical Management of Vesical Stones in Children: A Comparison Between Open Cystolithotomy, Percutaneous Cystolithotomy and Transurethral Cystolithotripsy With Holmium-YAG Laser

Treatment outcomes of bladder stones in children with intact bladders in developing countries: A systematic review of >1000 cases on behalf of the European Association of Urology Bladder Stones Guideline panel

INTRODUCTION

Bladder stones (BS) are still endemic in children in developing nations and account for a high volume of paediatric urology workload in these areas. The aim of this systematic review is to comparatively assess the benefits and risks of minimally invasive and open surgical interventions for the treatment of bladder stones in children.

METHODS

This systematic review was conducted in accordance with Cochrane Guidance. Database searches (January 1970- March 2021) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and non-randomised studies (NRSs) with >10 patients per group. Open cystolithotomy (CL), transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), extracorporeal shock wave lithotripsy (ESWL) and laparoscopic cystolithotomy (LapCL) were evaluated.

RESULTS

In total, 3040 abstracts were screened, and 8 studies were included. There were 7 retrospective non-randomised studies (NRS's) and 1 quasi-RCT with 1034 eligible patients (CL: n=637, TUCL: n=196, PCCL: n=138, ESWL: n=63, LapCL n=0). Stone free rate (SFR) was given in 7 studies and measured 100%, 86.6%-100%, and 100% for CL, TUCL and PCCL respectively. CL was associated with a longer duration of inpatient stay than PCCL and TUCL (p<0.05). One NRS showed that SFR was significantly lower after 1 session with outpatient ESWL (47.6%) compared to TUCL (93.5%) and CL (100%) (p<0.01 and p<0.01 respectively). One RCT compared TUCL with laser versus TUCL with pneumatic lithotripsy and found that procedure duration was shorter with laser for stones <1.5cm (n=25, p=0.04).

CONCLUSION

In conclusion, CL, TUCL and PCCL have comparable SFRs but ESWL is less effective for treating stones in paediatric patients. CL has the longest duration of inpatient stay. Information gathered from this systematic review will enable paediatric urologists to comparatively assess the risks and benefits of all urological modalities when considering surgical intervention for bladder stones.

Comparison of the Safety and Efficacy of Laser Versus Pneumatic Intracorporeal Lithotripsy for Treatment of Bladder Stones in Children

This study aimed to compare the safety and efficacy of laser lithotripsy and pneumatic lithotripsy, the two most commonly used transurethral lithotripsy methods for treating bladder stones in children in Iraq. Between January 2013 and December 2016, 64 children with bladder stones were included in this prospective randomized study, after ethical committee approval and written consent from the children’s parents or caregivers were obtained. Patients were assigned randomly by computer software to two groups treated with either pneumatic cystolithotripsy or laser lithotripsy. A 9 Fr. semirigid ureteroscope was used to pass the lithotripter through and fragment the stone. A catheter of 8–12 Fr. was then introduced and kept in place for 24 h. All children were hospitalized for 24 h, and the catheter was removed the next morning. Outpatient follow-up was maintained for 6–12 months. In terms of operation outcomes and complications, the laser lithotripsy group had a significantly longer duration of operation (74.5 ± 26.6 min vs. 51.5 ± 17.2 min, p = 0.001), whereas the number of patients requiring an extended hospital stay was significantly higher in the pneumatic lithotripsy group (48.5% vs. 16.1%, p = 0.006). Moreover, pneumatic lithotripsy was associated with a significantly greater risk of having at least one adverse effect (64% greater than that in the laser group). Stone clearance rates did not significantly differ between treatment groups. In conclusion, both pneumatic and laser lithotripters can be used to treat children with bladder stones with high efficacy and safety.

Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? A Review Article

Several therapeutic approaches such as holmium laser enucleation of the prostate (HoLEP) have been introduced to relieve bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Compared with other techniques including the transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP results in a shorter hospital stay and catheterization time and fewer blood loss and transfusions. HoLEP is a size-independent treatment option for BPH with average gland size from 36 g to 170 g. HoLEP is a safe procedure in patients receiving an anticoagulant and has no significant influence on the hemoglobin level. Also, HoLEP is an easy and safe technique in patients with a prior history of prostate surgery and a need for retreatment because of adenoma regrowth. The postoperative erectile dysfunction rate of patients treated with HoLEP is similar to TURP or open prostatectomy and about 77% of these patients experience loss of ejaculation. Patients with transitional zone volume less than 30 mL may suffer from persistent stress urinary incontinence following HoLEP so other surgical techniques like bipolar TURP are a good choice for these patients. In young patients, considering HoLEP with high prostate-specific antigen density and a negative standard template prostate biopsy, multiparametric MRI needs to be considered to exclude prostate cancer.

Minimally Invasive Management of Bladder Stones in Children

Background: Bladder stones (BS) are rare in children. Minimally invasive surgery (MIS) seems to be nowadays the procedure of choice to treat pediatric patients with BS. This study aimed to analyze retrospectively our experience with percutaneous cystolithotomy, endourological treatment with Holmium laser and robotic cystolithotomy in children with BS. Methods: We retrospectively analyzed the data of 13 children (eight boys and five girls) with BS who were treated at our centers between July 2013 and July 2020. The patients received three different MIS procedures for stones removal: five underwent robotic cystolithotomy, five underwent endourological treatment and three received percutaneous cystolithotomy (PCCL). We preferentially adopted endourological approach for stones <10 mm, percutaneous approach between 2014 and 2016 and robotic approach since 2016 for larger stones. Results: Mean patients' age at the time of diagnosis was 13 years (range 5-18). Ten/13 patients (76.9%) had primary BS and 3/13 patients (23.1%) had secondary BS. Mean stone size was 18.8 mm (range 7-50). In all cases the stones were removed successfully. One Clavien II post-operative complication occurred following PCCL (33.3%). All the procedures were completed without conversions. Operative time ranged between 40 and 90 min (mean 66) with no significant difference between the three methods (p = 0.8). Indwelling bladder catheter duration was significantly longer after PCCL (mean 72 h) compared with robotic and endourological approaches (mean 15.6 h) (p = 0.001). Hospitalization was significantly longer after PCCL (mean 7.6 days) compared with the other two approaches (mean 4.7 days) (p = 0.001). The endourological approach was the most cost-effective method compared with the other two approaches (p = 0.001). Conclusions: Minimally invasive management of bladder stones in children was safe and effective. Endourological management was the most cost-effective method, allowing a shorter hospital stay compared with the other procedures but it was mainly indicated for smaller stones with a diameter < 10 mm. Based upon our preliminary results, robotic surgery seemed to be a feasible treatment option for BS larger than 15-20 mm. It allowed to remove the big stones without crushing them with a safe and easy closure of the bladder wall thanks to the easy suturing provided by the Robot technology.

Retrograde-Assisted Percutaneous Cystolitholapaxy Versus Transurethral Cystolithotripsy With Holmium-YAG Laser: A Retrospective Study

Introduction: The retrograde approach is a modification that makes the percutaneous cystolitholapaxy (PCCL) a more trendy method, especially in operating rooms with limited facilities. The transurethral approach for bladder calculi lithotripsy by a laser has become popular among urologists. In this study, we investigate the feasibility and safety of retrograde assisted access for PCCL in comparison with transurethral cystolithotripsy by the holmium-YAG laser (Ho: YAG). Methods: According to the type of intervention, the patients were stratified to two matched groups. In the retrograde-assisted percutaneous cystolitholapaxy (RPCCL) group, a Benique was conducted through the urethra into the bladder; palpating the suprapubic region, an about 1.5 cm incision was done over the tip, then an Amplatz sheath was placed over it, treading into the bladder; further cystolitholapaxy was done by a routine order. In transurethral Ho: YAG laser lithotripsy (TULL) via 200 µm fiber vaporize the stone. Results: A total of 124 male patients with the mean age of 50.33±9.64 years and the average stone burden of 3.35±1.07 cm were included in the study. The most common cause of vesical calculi was spinal cord injury. Statistically significant differences were found in terms of the mean operation time in favor of the RPCCL group (P≤0.05) and the mean hospital stay in favor of the TULL group (P≤0.05). The stone-free rate (SFR) was 100% in both methods after a onemonth follow-up. None of the interventions changed to open surgery. There were not any major complications in both methods. Conclusion: RPCCL is a safe and effective method in bladder stone treatment and is applicable in medical centres without Ho: YAG equipment.

Comparison of Stone Retrieval Basket, Stone Cone and Holmium Laser: Which One Is Better in Retropulsion and Stone-Free Status for Patients with Upper Ureteral Calculi?

Introduction: Transurethral lithotripsy (TUL) is an appropriate treatment for ureteral stones and is usually used for stones in the middle and lower part of the ureter. Different devices such as the Holmium laser, the stone basket, and the stone cone exist to prevent any fragments from retropulsion during TUL. The present study aims to compare the advantages and disadvantages of the Holmium laser, the stone basket, and the stone cone. Methods: A retrospective study was conducted from September 2016 to January 2018 comparing various TUL methods in 88 subjects with proximal ureteral calculi. The study participants were divided into 4 matched groups. The first one included 20 patients undergoing TUL with no device (group 1), the second group included 22 patients undergoing TUL while using the stone retrieval basket, the third group included 18 patients undergoing TUL while utilizing the stone cone and the fourth group included 28 patients undergoing TUL while using the Hol-YAG laser. Results: A residual stone ≥3 mm was recorded in 15.9% of the patients. The stone free rate was seen in 100%, 90.9, 83.3%, and 55% of the Holmium laser group, the retrieval basket group, the stone cone group and the no device group respectively (P=0.001). The lowest rate of surgery complications including ureteral perforation, post-operative fever, and mucosal damage between the 4 groups (P=0.003) and the highest time of surgery (P=0.001) belonged to the laser group. If we want to ignore the laser group, the success rate for lithotripsy was better in both groups with a stone retrieval device compared to the no device group, but no advantage existed between the stone basket and the stone cone. Conclusion: We can safely conclude that lasers significantly help to prevent stone migration during TUL. If we want to ignore the laser group, the success rate for lithotripsy was significantly better in both groups with a stone retrieval device compared to the no device group, but no advantage existed between the stone basket and the stone cone.

Experience of 138 Transurethral Urethrotomy With Holmium:YAG Laser

Introduction: Many valid option modalities are available for the management of urethral stricture disease (USD), such as internal urethrotomy which has the success rates of 33%-60%. The aim of this study was to assess the outcome of holmium: YAG (Ho: YAG) laser urethrotomy (HLU). Methods: One hundred thirty-eight patients with urethral stricture with the mean age of 48±3.03 years old treated by HLU from March 2011 to August 2017. The main purpose of this investigation was to evaluate mean operation time, stricture recurrence rate and post-operation Qmax and complications of transurethral HLU. Results: The most common cause of USD was trauma in 82 (59.4%) patients. Mean laser operation time, mean hospital stay and mean postoperative duration of catheterization were 23.08 ± 9.1 minutes, 19.02 ± 10.7 hours and 10.3 ± 1.05 days respectively. The mean Qmax was 8.3 ± 2.07 mL/s before surgery and 16 ±3.1 mL/s afterward. At the end of 12 months follow-up, a total of 37 (26.8%) patients developed recurrence of the stricture. Patients with posterior, longer urethral strictures and previous history of interventions have more recurrence rate of the stricture. Conclusion: HLU is minimally invasive and seems to be an effective and safe management option for primary, short, urethral strictures. The hospital stay is remarkably short and complications are negligible.

Is Holmium Laser an Appropriate Modality to Treat Genital Warts?

Introduction: Genital warts in young adults aged 18-28 years are very common. Several approaches are routinely used in the treatment of warts, viz., medical treatment (podophyllin and trichloroacetic acid), conventional surgery (excision or electrocautery), cryotherapy, and laser treatment. Because of high recurrence rates after treatment, complications and long duration of treatment, newer modalities have been developed. One of these newer methods is laser, which has been used in several urologic diseases. However, there are only a few studies about use of Holmium laser for treatment of genital warts. This retrospective study compared the success rate of Holmium laser with other available treatments for genital warts. Methods: Between October 2011 and May 2016, 142 patients with genital warts attended the urology clinics at Shohada-e-Tajrish hospital in Tehran, Iran. Out of these, a total of 101 patients were included in this study consisting of 42, 39, 11 and 9 patients treated with cryotherapy, laser, conventional surgery and podophyllin respectively. Results: The most successfully cleared lesions were seen in the holmium laser treatment group (P=0.001). The lowest recurrence rate was observed in the holmium laser treatment group (P=0.001). 17 patients had one of these following problems: dysuria, initial hematuria or a change in the force and caliber of their urinary stream that after physical examination showed them to have a meatal wart. These patients then underwent cystoscopy up to urinary sphincter. All of them in addition to the meatus wart had a penile shaft lesion(s). Thirteen patients had meatal lesions, 9 of whom received holmium laser therapy and 4 patients were treated with electrocautery. Based on routine follow up after treatment, none of the patients treated with holmium laser had urinary stricture, but one case treated with electrocautery returned with a penile urethral stricture. Conclusion: This study showed that treatment with Holmium laser has the highest clearance rate (92.2%) and lowest recurrence rate (14.3%) compared to other available treatments in this study. It may be concluded that holmium laser is a safe and effective treatment for genital warts with a low rate of recurrence.

Pneumatic Lithotripsy Versus Laser Lithotripsy for Ureteral Stones

Introduction: Several different modalities are available for ureteral stone fragmentation. From them pneumatic and holmium: yttrium-aluminum-garnet (Ho: YAG) lithotripsy have supportive outcomes. In this study we studied 250 subjects who had ureteroscopic pneumatic lithotripsy (PL) or laser lithotripsy (LL). Methods: Two-hundred fifty patients with ureteral stones underwent ureteroscopic lithotripsy (115 subjects in the PL group, 135 subjects in the LL group) from August 2010 to April 2016. The purpose of this investigation was to evaluate stone-free rate (SFR), mean operation time (MOT), mean hospital stay (MHS), stone migration and complications. Results: Two groups were similar in age, gender, mean size of stones, side of stone, and complications. There was a statistical difference in terms of SFR, stone migration and MHS in favor of the LL group (P ≤ 0.05, P ≤ 0.05 respectively), and MOT in favor of the PL group (P ≤ 0.05). Conclusion: Both the PL and LL techniques were effective and safe for ureteral stones, however a slightly higher SFR was found in the LL group.