Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center

Preference for diagnosing and treating renal colic during pregnancy: a survey among Chinese urologists

To explore the preference for diagnosing and treating renal colic during pregnancy among Chinese urologists. A questionnaire was designed using the Sojump® platform. WeChat, the largest social networking platform in China, was used to distribute the questionnaire to urologists at hospitals of all levels in China. In total, 110 responses were included. Of the respondents, 100.0% used ultrasound to diagnose renal colic during pregnancy, followed by magnetic resonance imaging (17.3%) and low-dose CT (3.6%). Phloroglucinol (80.9%) and progesterone (72.7%) were the most commonly used antispasmodics and analgesics. Opioid analgesics were not commonly used (12.7%). Most of the respondents (63.6%) indicated that no more than 20% of the patients needed surgical intervention. If surgery was unavoidable, 95.5% preferred temporary renal drainage, including ureteral stenting (92.7%) and percutaneous nephrostomy (2.7%). However, some respondents still preferred definitive stone treatment, such as ureteroscopy lithotripsy (3.6%) and percutaneous nephrolithotomy (0.9%). Moreover, there were no differences in the choices of urologists with different professional titles regarding diagnostic tools, most therapeutic medications, or surgical methods (p > 0.05). Ultrasound is the preferred tool for diagnosing renal colic during pregnancy. Low-dose CT is still not widely accepted. Pregnant patients with renal colic are initially treated conservatively. Urologists prefer ureteral stenting when there are clinical indications for intervention.

Comparison of Radiation Exposure for Pregnant Patients Requiring Intervention for Suspected Obstructing Nephrolithiasis

OBJECTIVE

To identify the differences in radiation exposure per suspected stone episode between percutaneous nephrostomy tube (PCN), stent, and primary ureteroscopy (URS).The incidence of nephrolithiasis in pregnancy is low; however, repercussions for both mother and fetus can be significant. In cases of suspected obstructing nephrolithiasis, intervention may be required, including ureteral stent, PCN, or URS, with the potential for multiple subsequent procedures that often utilize fluoroscopy.

METHODS

Pregnant patients who required an intervention (stent, PCN, or URS) for suspected obstructing nephrolithiasis were retrospectively reviewed. The primary outcome was total fluoroscopy exposure per suspected stone episode. Secondary outcomes included fluoroscopic exposure per procedure and number of procedures required.

RESULTS

After excluding patients with renal anomalies and incomplete radiation data, 78 out of 100 patients were included in the analysis. Forty patients (51.3%) underwent initial stent placement, 22 (28.2%) underwent initial PCN placement, and 16 (20.5%) underwent primary URS. Total mean radiation exposure per stone episode was significantly higher in patients who underwent PCN, (286.9 mGy vs 3.7 mGy (stent) and 0.2 mGy (URS), P <.001). In addition, patients who underwent initial PCN placement had significantly more procedures (P <.001) and mean radiation exposure per procedure was higher (P <.001). More than 40% of PCNs experienced dysfunction, and mean duration between PCN exchanges was 16.5 days.

CONCLUSION

In pregnant patients with suspected obstructing nephrolithiasis requiring intervention, initial PCN placement was associated with a significantly higher number of procedures, radiation exposure per procedure, and total radiation exposure per suspected stone episode compared to stent and URS.

Contemporary Use of Computed Tomography (CT) Imaging in Suspected Urolithiasis in Pregnancy

PURPOSE OF REVIEW

We aimed to examine the role of low-dose CT (LDCT) in the diagnostic work-up for suspected urolithiasis in pregnancy. We reviewed contemporary urologic recommendations for CT in pregnancy, its utilization for suspected urolithiasis, and explored barriers to its use.

RECENT FINDINGS

National urologic guidelines and the American College of Obstetricians and Gynecologists recommend the judicious use of LDCT imaging in pregnancy when necessary. We noted inconsistencies in review article management pathways and recommendations for CT imaging for suspected urolithiasis in pregnancy. Overall CT utilization in pregnancy for suspected urolithiasis is low. Proposed barriers to LDCT use in pregnancy include fears of litigation and misperceptions of the harm of diagnostic radiation. Recent advancements in imaging technologies for urolithiasis in pregnancy are limited. More specific diagnostic pathway recommendations from national urologic guideline bodies for when to use LDCT to investigate renal colic in pregnancy may reduce diagnostic and intervention delays.

Analysis of uroseptic shock after ureteroscopy for ureteral calculi during pregnancy: a case report

BACKGROUND

Uroseptic shock secondary to ureteral calculi during pregnancy is rare. It is characterized by rapid onset, rapid progression, aggressive disease, limited treatment, poor prognosis, and a mortality rate higher than 20% with improper or delayed management. A clear diagnosis is made based on typical clinical symptoms and abdominal ultrasound, often requiring combined multidisciplinary treatment and the simultaneous release of the obstruction. The high mortality rate is mainly related to inappropriate early treatment of stones and infections or failure to intervene in a timely manner.

CASE PRESENTATION

A 21-year-old first-time pregnant patient with uroseptic shock was admitted to our intensive care unit. The patient was successfully treated at our hospital with multidisciplinary cooperation, high-dose vasoactive drugs, IABP, CRRT, VA-ECMO, and termination of pregnancy.

CONCLUSIONS

Timely relief of obstructions, termination of pregnancy, and the provision of IABP, CRRT, and VA-ECMO when necessary in critically ill patients with uroseptic shock during pregnancy can improve the success rate of resuscitation.

Ureteroscopic lithotripsy of ureteric stone using thulium fiber laser in a pregnant patient, case report

Nephrolithiasis represents a common cause of non-obstetrical abdominal pain during pregnancy with 1 out of 200 pregnancies being affected. 20%-30% of patients require ureteroscopy. Many studies were done on safety of holmium:yttrium-aluminium-garnet (YAG) during pregnancy but none on Thulium Fiber Laser (TFL). To our knowledge, this is the first reported case of pregnant patient with nephrolithiasis that was treated using ureteroscopy and TFL. We present a 28 years old pregnant woman that presented to our hospital with a left distal ureteric stone. Patient underwent URS and lithotripsy using TFL. The procedure was tolerated with no complications.

A critical appraisal of urolithiasis clinical practice guidelines using the AGREE II instrument

Background

The Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument was developed to improve the methodological quality of clinical practice guidelines (CPGs). High-quality guidelines can provide reliable recommendations for different clinical issues. Currently, there is no quality appraisal of CPGs for urolithiasis. This study evaluated the quality of evidence-based CPGs for urolithiasis and provided new insights into improving guideline quality on urolithiasis.

Methods

Systematic reviews were conducted to identify urolithiasis CPGs in PubMed, electronic databases, and websites of medical associations from January 2009 to July 2022. The quality of included CPGs was evaluated by four reviewers using the AGREE II instrument. Subsequently, the scores of all domains in the AGREE II instrument were calculated.

Results

A total of 19 urolithiasis CPGs were identified for review: seven from Europe, six from USA, three from international union, two from Canada, and one from Asia. The agreement among reviewers was rated good [intraclass correlation coefficient (ICC), 0.806; 95% CI: 0.779-0.831]. The domains with the highest scores were scope and purpose (69.7%, 54.2-86.1%) and clarity of presentation (76.8%, 59.7-90.3%). The domains of stakeholder involvement (44.9%, 19.4-84.7%) and applicability (48.5%, 30.2-72.9%) gained the lowest score. Only five guidelines (26.3%) were considered "strongly recommended".

Conclusions

The overall quality of the eligible CPGs was relatively high; however, future work is still needed in the domains of rigor of development, editorial independence, applicability, and stakeholder involvement.