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Lepine HL, Vicentini FC, Mazzucchi E, Molina WR, Marchini GS, Torricelli FC, Batagello CA, Danilovic A, Nahas WC. Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis. Int Braz J Urol 2024; 50:250-260. [PMID: 38598828 PMCID: PMC11152329 DOI: 10.1590/s1677-5538.ibju.2024.0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/04/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. METHODS This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. RESULTS A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. CONCLUSION This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.
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Affiliation(s)
- Henrique L. Lepine
- Faculdade de Medicina da Universidade de São PauloSão PauloSPBrasilFaculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Fabio C. Vicentini
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Eduardo Mazzucchi
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Wilson R. Molina
- University of KansasEndourology SectionDepartment of UrologyKansasKSUSADepartment of Urology, Endourology Section, University of Kansas, Kansas City, KS, USA
| | - Giovanni S. Marchini
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Fabio C. Torricelli
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Carlos A. Batagello
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - Alexandre Danilovic
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
| | - William C. Nahas
- Universidade de São PauloFaculdade de MedicinaDepartamento de Urologia do Hospital das ClínicasSão PauloSPBrasilDepartamento de Urologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil;
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Hartung FO, Müller KJ, Herrmann J, Grüne B, Michel MS, Rassweiler-Seyfried MC. Comparison of endoscopic versus CT assessment of stone-free status after percutaneous nephrolithotomy (PCNL). Urolithiasis 2023; 51:120. [PMID: 37801124 PMCID: PMC10558392 DOI: 10.1007/s00240-023-01495-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
This study is aimed to determine whether postoperative low dose computed tomography (LDCT) imaging is necessary after percutaneous nephrolithotomy (PCNL), or the surgeon's intraoperative assessment of residual fragments (RF) is sufficient and avoidance of postoperative imaging with reduction of radiation exposure can be achieved. Data of all 610 patients who underwent PCNL in prone position in our institution from February 2009 to September 2020 was collected. Parameters such as age, gender, BMI, ASA-Classification, stone related parameters and the surgeon's assessment of stone-free status were analyzed. The LDCT performed postoperatively was compared to the intraoperative assessment of the surgeon regarding RF. The mean age of patients was 52.82 years; the mean BMI was 28.18 kg/m2. In 418 cases, the surgeon made a clear statement about the presence of RF and postoperative LDCT was carried out. The discrepancy between the two methods (surgeon´s assessment vs. LDCT) was significant at p < 0.0001. The sensitivity, specificity, positive and negative predictive value of the surgeon when assessing RF were 24.05%, 99.45%, 98.28% and 50%. Stone free rate (SFR) after primary PCNL was 45.57%. The overall SFR at discharge was 96.23%. Although the surgeon´s assessment of RF was reliable, postoperative LDCT imaging should still be performed if endoscopic stone clearance is suspected due to the high false negative rate and the low negative predictive value. The optimal timing of postoperative imaging following PCNL remains unclear.
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Affiliation(s)
- F. O. Hartung
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - K. J. Müller
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - J. Herrmann
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - B. Grüne
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - M. S. Michel
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - M. C. Rassweiler-Seyfried
- Department of Urology and Urologic Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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Patel PM, Kandabarow AM, Chuang E, McKenzie K, Druck A, Seffren C, Blanco-Martinez E, Capoccia E, Farooq AV, Branch J, Turk T, Baldea K. Using Intraoperative Portable CT Scan to Minimize Reintervention Rates in PCNL: A Prospective Trial. J Endourol 2022; 36:1382-1387. [PMID: 35620899 DOI: 10.1089/end.2022.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE More than 40% of patients undergoing PCNL are left with residual stone fragments and often require secondary procedures. Portable CT (PCT) technology allows surgeons to obtain intraoperative cross-sectional imaging, identify and extract residual stones immediately, and thereby reduce the need for subsequent procedures. This prospective trial evaluates how incorporation of PCT during PCNL affects perioperative outcomes. PATIENTS AND METHODS We prospectively enrolled eligible patients undergoing initial PCNL for this trial (n=60), which entailed a single intraoperative CT-abdomen and ipsilateral antegrade ureteroscopy when the surgeon felt stone treatment was visually complete. If residual fragments were identified, the surgeon continued nephroscopy to find and remove them; if not, the procedure was concluded. These patients were compared to a retrospective cohort (n=174) who underwent initial PCNL with post-operative imaging performed the following day. RESULTS The two cohorts had similar demographic properties and stone characteristics, and location of percutaneous access. In the prospective arm, 50% of intraoperative PCT scans identified residual fragments, prompting continuation of surgery to remove them. This cohort had significantly higher stone-free rate (82% vs. 36%, p<0.01), lower rate of planned reintervention (7% vs. 32%, p<0.01), lower rate of urgent presentation with ureteral obstruction (0% vs. 7%, p=0.04), lower total CT-based effective radiation dose (8.4 vs. 14.6 mSv, p<0.01), and shorter length of stay (2.3 vs. 3.5 days, p<0.01) when compared to the retrospective cohort that did not use intraoperative PCT. CONCLUSIONS Obtaining an intraoperative portable CT scan during PCNL can substantially improve perioperative outcomes. Further evaluation of this modality through a randomized-controlled trial is warranted.
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Affiliation(s)
- Parth M Patel
- UCLA, 8783, 1260 15th St., Suite 1200, Los Angeles, California, United States, 90404;
| | - Alexander M Kandabarow
- Loyola University Medical Center, 25815, Urology, 2160 S 1st Ave, Building 54, Room 237A, Maywood, Illinois, United States, 60153;
| | - Eric Chuang
- Loyola University Chicago Stritch School of Medicine, 12248, Maywood, Illinois, United States;
| | - Kevin McKenzie
- Loyola University Chicago Stritch School of Medicine, 12248, Maywood, Illinois, United States;
| | | | - Christopher Seffren
- Loyola University Chicago Stritch School of Medicine, 12248, Maywood, Illinois, United States;
| | - Enrique Blanco-Martinez
- Loyola University Chicago Stritch School of Medicine, 12248, Maywood, Illinois, United States;
| | - Edward Capoccia
- Loyola University Medical Center, 25815, Urology, Maywood, Illinois, United States;
| | - Ahmer V Farooq
- Loyola University Medical Center, 25815, Urology, Maywood, Illinois, United States;
| | - Jeffrey Branch
- Loyola University Medical Center, 25815, Urology, Maywood, Illinois, United States;
| | - Thomas Turk
- Loyola University Medical Center, 25815, Urology, Maywood, Illinois, United States;
| | - Kristen Baldea
- Loyola University Medical Center, 25815, Urology, Maywood, Illinois, United States;
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Videourology Abstracts. J Endourol 2021. [DOI: 10.1089/end.2021.29116.vid] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dyna-CT-Based Three-Dimensional Cholangiography in Biliary Duct Assessment of Hilar Cholangiocarcinoma. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Van den Broeck T, Zhu X, Kusters A, Futterer J, Langenhuijsen J, d'Ancona F. Percutaneous Nephrolithotomy with Intraoperative Computed Tomography Scanning Improves Stone-Free Rates. J Endourol 2020; 35:267-273. [PMID: 32689828 DOI: 10.1089/end.2020.0365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Introduction: The use of fluoroscopy during percutaneous nephrolithotomy (PCNL) may lead to an overestimation of stone-free rates. The objective of this study is to demonstrate the feasibility of intraoperative CT-guided PCNL compared with standard of care (SoC) PCNL. Patients and Methods: A prospective feasibility study (20 patients undergoing PCNL with an intraoperative CT scan between June 2017 and February 2020) and a retrospective study of a historical cohort (20 consecutive patients undergoing SoC PCNL between September 2015 and September 2016) were conducted. All procedures were performed by an expert endourologist in a tertiary referral hospital. Follow-up was performed at 6 weeks postoperatively. The primary goal is to investigate the practicality and potential benefits and harms of intraoperative CT scanning during PCNL. Secondary outcomes are a stone-free rate after the 6-week follow-up, perioperative radiation exposure, the need for postoperative imaging, and peri- and postoperative complications. Statistical significance was considered at p < 0.05. Results: The initial stone-free rate in the CT scan group was 65% (n = 13). In 25% (n = 5) of patients, residual stone fragments were removed after the perioperative CT scan. In the SoC group, 85% (n = 17) of patients were thought to be stone free perioperatively. At the 6-week follow-up, 80% (n = 16) in the CT scan group vs 50% in the SoC group (n = 10) were found to be stone free. Radiation exposure, perioperatively, was higher in the CT scan group. Complications were comparable between groups. Limitations of the study are the nonrandomized design of the study and nonstandardized follow-up imaging. Conclusions: Intraoperative CT scanning during PCNL is feasible and gives a better estimate of any remaining stone fragments compared with fluoroscopy only.
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Affiliation(s)
- Thomas Van den Broeck
- Radboud University Medical Center, Nijmegen, The Netherlands.,University Hospitals Leuven, Leuven, Belgium
| | - Xiaoye Zhu
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anneke Kusters
- Radboud University Medical Center, Nijmegen, The Netherlands.,Regional Hospital Queen Beatrix, Winterswijk, The Netherlands
| | - Jurgen Futterer
- Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Frank d'Ancona
- Radboud University Medical Center, Nijmegen, The Netherlands
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Baralo B, Samson P, Hoenig D, Smith A. Percutaneous kidney stone surgery and radiation exposure: A review. Asian J Urol 2019; 7:10-17. [PMID: 31970066 PMCID: PMC6962710 DOI: 10.1016/j.ajur.2019.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/06/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022] Open
Abstract
During the past 3 decades, radiation exposure (RE) has increased drastically among patients undergoing percutaneous nephrolithotomy (PCNL), thus potentially causing new cases of cancer each year. The effective dose received by patients comes from pre- and post-operative computed tomography (CT) and intraoperative fluoroscopy (FL). We reviewed literature to find novel techniques and approaches that help to decrease RE of patients and personnel. We performed PubMed search using keywords percutaneous nephrolithotomy, intraoperative fluoroscopy, radiation exposure, imaging, percutaneous access, ultrasound, computed tomography, endoscopy, reconstruction, innovations, and augmented reality. Forty-four relevant articles were included in this review. As much as 20% of patients with first diagnosed urolithiasis exceed background RE level almost 17-fold. For diagnosing purposes using low-dose and ultra-low-dose CT, as well as low-dose dual energy scan protocols can be efficient ways to decrease RE while maintaining decent accuracy. Patients with urinary stones can be effectively monitored with digital tomosynthesis, ultrasound alone or ultrasound combined with plain film of the abdomen. Percutaneous access (PCA) into the kidney can be performed with reduced or even no RE, using novel PCA methods. REs from conventional imaging techniques during diagnosis and treatment increase probability of non-stochastic radiation effects. Urologists should be aware of protocols that decrease RE from CT and FL in diagnosis and management of urinary stones. Consideration of recently developed imaging modalities and PCA techniques will also aid in adherence to the “as low as reasonably achievable” principle.
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Affiliation(s)
- Bohdan Baralo
- Urology Department, National Pirogov Memorial Medical University, Vinnytsya, Ukraine
| | - Patrick Samson
- Department of Urology, Smith Institute for Urology, Northwell Health, New Hyde Park, NY, USA
| | - David Hoenig
- Department of Urology, Smith Institute for Urology, Northwell Health, New Hyde Park, NY, USA
| | - Arthur Smith
- Department of Urology, Smith Institute for Urology, Northwell Health, New Hyde Park, NY, USA
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Bernstein DE, Bernstein BS. Urological technology: where will we be in 20 years' time? Ther Adv Urol 2018; 10:235-242. [PMID: 30034542 PMCID: PMC6048627 DOI: 10.1177/1756287218782666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/23/2018] [Indexed: 12/18/2022] Open
Abstract
Since prehistoric times, our understanding of urology has rapidly expanded. Whilst primitive urologists began by using urine as a therapeutic substance, modern urologists may find themselves removing a kidney remotely by driving a robotic arm, with seven degrees of movement, while using image overlay-augmented reality. This review provides an insight into the potential status of urological technology in 20 years' time, assessed through an analysis of developments in imaging, diagnostics, robotics and further technologies. A particular emphasis is given to the promising fields of minimally invasive techniques, nanotechnology and tissue engineering, which likely hold the key to a new era for urology.
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