2022 Recommendations of the AFU Lithiasis Committee: Ureteroscopy and ureterorenoscopy

Technical advances, including miniaturization, have improved the deflection and optical performance of the ureteroscopes, and the availability of dedicated disposable devices have led to their increasing use for kidney and ureteral stone management. Ureterorenoscopy brings diagnostic evidence through the endoscopic description of stones and renal papillary abnormalities. Currently, intracorporeal lithotripsy during ureterorenoscopy is based on laser sources. Routine ureteral stenting is not necessary before ureterorenoscopy, especially because preoperative stenting for>30 days is considered as an independent risk factor of infection. Ureteral access sheaths allow the easy and repeated access to the upper urinary tract and thus facilitate ureterorenoscopy. Their use improves vision, decreases intrarenal pressure, and possibly reduces the operative time, but they may cause ureteral injury. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

2022 recommendations of the AFU Lithiasis Committee: Objectives, results, residual stones and fragments

The main objectives of interventional stone treatment are stone removal, symptom elimination, and kidney function preservation. After treatment of kidney stones (extracorporeal shock wave lithotripsy [ESWL], or endoscopy), fragments may remain in the kidney, either deliberately left in place or due to treatment failure (i.e. residual stone [RS], resistant to ESWL, left or inaccessible by endoscopy), or due to failure to eliminate the obtained fragments (i.e. residual fragments [RF]). Their management may differ. The most commonly used definition of RF in the literature is based on a size cut-off (≤4mm) and on three criteria: spontaneous clearance rate, secondary intervention rate, and disease progression rate. RF may be spontaneously eliminated (42%), persist and increase in size (32%), or become complicated and require a secondary urological procedure (36%). Like for the initial treatment, it is important to consider the stone composition for the treatment decision-making concerning RS/RF. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU, 2022) and their adaptability to the French context.

[Recommendations of the Urolithiasis Committee of the French Urology Association for the management and the treatment of the stone formers patients during the COVID-19 pandemic crisis]

Confrontés à une crise d’une ampleur exceptionnelle liée à la pandémie à coronavirus COVID-19 responsable d’une saturation selon les régions des urgences et des places en réanimation, le Comité Lithiase de l’Association Française d’Urologie (CLAFU) a élaboré pour la première fois les recommandations de prise en charge des calculs urinaires durant cette crise sanitaire.

[Flexible ureteroscope damages. Evaluation of university hospital service equipment]

OBJECTIVE

To evaluate predictors of flexible ureterorenoscopes breakage and damage of their optical beam.

MATERIALS AND METHODS

Retrospective survey, single center on 393 interventions with 4 flexible ureterorenoscopes between January 2009 and March 2013. We analyzed factors linked to patient, pathology and surgical technique.

RESULTS

We identified 21 major accidents, a breakage rate of 5.34% and 76 pixels losses in the maintenance of endoscopes and 10 during the procedure. The only statistically significant predictor of loss was the cumulative duration of operating time since the last repair (P=0.04, OR=1.001 [1-1001]). For lesions of the optical beam between the procedures, parameters appearing as significant were the ureterorenoscope model (P=0.01, OR=2.558, 95% CI [1229-5326]), the use of instruments by the working channel: the laser (P=0.02, OR=2.06, 95% CI [1109-3827]), or the use of endoluminal graspers (P=0.007, OR=0.467, 95% CI [0269-0809]). Intraoperatively, the number of open or laparoscopic surgery (P=0.007, OR=3.105, 95% CI [1364-7068]), duration of intervention (P=0.01, OR=1.023, 95% CI [1.006-1041]) and the cumulative duration of intervention (P=0.003, OR=1.001, 95% CI [1-1002]) appeared to be statistically significant.

CONCLUSION

The only predictor of loss of equipment under repair was the cumulative duration of operation time. It has not been demonstrated any difference between ureterorenoscopes. It was during the endoscopes disinfection that the majority of optical beam lesions take place.

[Screening of prostate cancer seen by general practitioners]

INTRODUCTION

The screening of prostate cancer was recently the subject of international studies and debates in France. We decided to study the vision of the screening, in particular by the PSA, which have the general practitioners.

METHODS

We sent a questionnaire to 456 general practitioners of Oise (French department) to be returned in an anonymous way on the prostate cancer, PSA, the economic impact of the PSA and we asked whether the doctors realized the screening or not, if they were favorable to it and for which reasons.

RESULTS

We received 38% of answers. Eighty-one percent of the general practitioners considered that prostate cancer is frequent, 72% that it evolved slowly and 55% that it affected old men. For 79% of the general practitioners, the patients were asking for a screening by PSA. Eighty-eight percent thought that they had to be in front line of the screening, 58% that the functional consequences of the screening were satisfactory. Fifty-seven percent of the general practitioners realized the screening in a systematic way and 88% were favorable to it.

CONCLUSION

The general practitioners of Oise remained favorable for the greater part to the screening of prostate cancer and the patients applicants in spite of various debates.

[In-hospital stays for urolithiasis: analysis of French national data]

INTRODUCTION

Urolithiasis is of health economics concern since it is very frequent. However, there is few data upon its issue in France.

METHODS

We have analyzed the data issued from the national coding system for in-hospital stays and interventions, using urolithiasis codes and compared between public and private sectors. We have observed evolution of procedures and stays until 2009.

RESULTS

Public and private sectors were quite similar in terms of stays numbers (144,324 in 2009, and an evaluated total cost of more than 168 millions of euros). Since 2000, there has been an increase of more than 20% in the number of stays in the public sector and a stagnation in the private one. Public and private sectors appeared different in terms of: (1) stays without intervention (53 vs 26%; p<0.0001); (2) stays without associated diagnosis (5.78 vs 8.41%; p<0.0001). Since 2006, there has been a stagnation for percutaneous and surgical interventions (less than 5% of the number of interventions) whereas there has been a clear increase in endoscopic (+29% in private sector and +16% in public one) and lithotriptic (+19 and +5%) interventions.

CONCLUSION

There were strong disparities between public and private sectors. Endoscopic interventions and lithotrity sessions have shown a sustained increase. Surgical and percutaneous interventions have shown a stagnation.

[Radiotherapy influence, about results of the InVance(®) male sling in men with stress urinary incontinence]

AIMS

To study impact of previous radiotherapy on urodynamic parameters, continence and complication rate, after prosthetic implantation with InVance® device.

PATIENTS AND METHODS

We included 106 patients between August 2004 and March 2009. We stratified urinary incontinence according to pads daily used, in grade I (one to two pads), II (three to four), or III (more than four or condom catheter use). We compared one group of 24 patients with previous radiotherapy (R) to 82 control patients (T) without one. Follow-up was made at three and six postoperative months and then annually. Results were classified into: no leaks, improved or failure.

RESULTS

Mean follow-up was 14.8 months (median=12.8) in group R and 12.4 months (median=8.8) in group T. At three postoperative months, continence was achieved in 62.5% patients from group R and in 77% patients in group T (P: ns). At 12 months, results on continence were respectively 52.6% in group R and 63.2% in group T (P: ns). Six patients were explanted because of an infection (5.7%), among which two in group R (8.3%) and four in group T (4.8%). Infection was significantly linked to operative time (P: 0.02).

CONCLUSION

Previous radiotherapy has no impact on urodynamic parameters and continence, on short- and mid-term analysis, after implantation of a bone-anchored suburethral sling with InVance® device, preferentially patients with mild to moderate incontinenec urinary.

[Twinkling artifact on Doppler US: clinical presentations]

Twinkling artifact characterized by a rapidly fluctuating mixture of Doppler signals occurs behind a strongly reflecting granular interface such as urinary tract stones or gallstones. It may occurs in association with several clinical situations, and may sometimes be helpful for diagnosis while it may sometimes be a pitfall that must be recognized by the sonographer. After reviewing the technical nature of this artifact, several cases will be presented to illustrate the advantages and pitfalls related to this artifact.

[Cardiovascular risk associated with urolithiasis]

OBJECTIVE

Urolithiasis appears to be associated with several cardiovascular risk factors (excess salt and animal proteins, hypertension, metabolic syndrome) and, more recently, the development of stroke. The authors describe the frequency of cardiovascular risk factors and cardiovascular events before and after management of urolithiasis.

METHOD

The authors retrospectively collected data from patients born before 1956 and managed surgically or instrumentally for urolithiasis in our establishment in 1994 concerning the frequency of cardiovascular risk factors and the incidence of acute coronary syndrome, stroke or acute lower limb ischaemia before or after treatment of urolithiasis.

RESULTS

Data were obtained for 33 patients, revealing 12 events including five previous events (four cases of acute coronary syndrome, one ischaemic stroke) and seven subsequent events (five cases of acute coronary syndrome with one death, one ischaemic stroke, one case of acute lower limb ischaemia) an average of 5.7 years after management. These 33 patients had an average of more than two risk factors.

CONCLUSION

This retrospective study based on a small sample size demonstrated a high frequency of risk factors and cardiovascular events. This correlation needs to be studied in more detail. Urolithiasis could constitute an indirect cardiovascular risk factor dependent on "classical" risk factors, suggesting the need for integrated management of stone patients, in the same way as for patients with erectile dysfunction.

[Ureter drugs]

Many improvements have been made recently in the field of the ureteral smooth muscle pharmacology. After a brief summary on physiological basis, we review what is known about effects on ureter of different drugs class. In a second part, we review clinical applications for renal colic analgesia, calculi expulsive medical therapy, ESWL adjuvant treatment and preoperative treatment before retrograde access. There are now sufficient data on NSAID and alpha-blockers. beta-agonists, especially for beta3 selective ones, and topical drugs before retrograde access are interesting and should be further evaluated.

Common and Newly Identified Foliar Diseases of Seed-Producing Lucerne in France

A 4-year survey of seed-producing lucerne fields in the three main production regions of France, representing 10.000 ha and three types of climates, confirmed the presence of the foliar pathogens Pseudopeziza medicaginis, Ascochyta imperfecta, Stemphylium spp., Leptosphaerulina briosiana, and Uromyces striatus. Surprisingly, A. imperfecta often was found in association with Stemphylium-like symptoms. Further investigation revealed the presence of fungi until now only rarely found or unreported in France, such as Leptotrochila medicaginis, Cercospora medicaginis, and Stagonospora meliloti. The results showed that P. medicaginis and A. imperfecta were present on more than 50% of the samples. U. striatus and C. medicaginis also commonly were found and infected about 25% of the samples. L. medicaginis occurred primarily in the Southwest region.

A sensitive immunochemiluminescence assay for human serum amyloid A protein

We describe an immunochemiluminescence assay for human plasma serum amyloid A protein (SAA) in which specific rabbit polyclonal antibodies against synthetic peptides are used. The detection of the antigen-antibody reaction at 425 nm is based on a brief emission of light by a luminophor component (signal) in response to chemical energy. The working range of the assay covers plasma SAA concentrations from 5 to 100 micrograms/L. The lower detection limit is 5 micrograms/L, the within- and between-assay CVs are less than 12%. Bilirubin, cholesterol and triglyceride in final concentrations of up to 220 mumol/L, 8.1 mmol/L and 2.68 mmol/L, respectively, do not interfere with the assay. Results were correlated with those obtained by the enzyme-linked immunosorbent assay using the same antibodies (r = 0.95; p less than 0.001; n = 50). This method is inexpensive, simple and easily automated.

Serum apolipoproteins A-I, A-II and B in hepatic metastases. Comparison with other liver diseases: hepatomas and cirrhosis

Serum concentrations of lipids and apolipoprotein A-I, A-II and B were determined in patients with hepatic metastases of colorectal cancer, with primary liver cancer and with cirrhosis. In all three liver diseases, the HDL fraction and apolipoproteins A-I and A-II showed significantly low values, while apolipoprotein B was only increased in hepatic metastases. The decrease of apolipoprotein A-II levels was more prominent in cirrhosis, thereby enhancing the A-I/A-II ratio. This ratio is decreased in metastasis and normal in hepatomas. In patients with hepatic metastases a correlation was observed between alkaline phosphatase and apolipoprotein A-II (p less than 0.05), and between gamma-glutamyltransferase and the A-I/A-II ratio (p less than 0.05). The present work suggests that determination of apolipoproteins and lipids of the HDL fraction offers a new approach to the study of liver diseases.

Automated immunoturbidimetric assay of serum apolipoprotein A-II using the Cobas-Bio centrifugal analyser: influence of hyperlipoproteinemia

A quantitative automated immunoturbidimetric procedure for the analysis of apolipoprotein A-II (Apo A-II) in human serum is described. Dilution of antibody with a 5% solution of PEG 6000 enhanced the quantification. The within- and between-assay coefficients of variation were less than 5%. Results correlated well with those obtained by classic electroimmunodiffusion and immunonephelometry. No extraction of samples with organic solvent was necessary, whatever the triglyceride concentration. Large lipoproteins such as VLDL and immunocomplexes did not affect the method, nor was there interference from icteric or hemolyzed serum or from serum with excessive hyperlipemia. Physiological values of Apo A-II were determined in a normal population. Concentrations were found to be age-dependent, and higher in women than in men. The procedure is very suitable for the rapid, precise, reproducible and inexpensive assay of Apo A-II.