Treatment selection for urolithiasis: percutaneous nephrolithomy, ureteroscopy, shock wave lithotripsy, and active monitoring

Urolithiasis is a significant worldwide source of morbidity, constituting a common urological disease that affects between 10 and 15% of the world population. Recent technological and surgical advances have replaced the need for open surgery with less invasive procedures. The factors which determine the indications for percutaneous nephrolithotomy include stone factors (stone size, stone composition, and stone location), patient factors (habitus and renal anomalies), and failure of other treatment modalities (ESWL and flexible ureteroscopy). The accepted indications for PCNL are stones larger than 20 mm², staghorn and partial staghorn calculi, and stones in patients with chronic kidney disease. The contraindications for PCNL include pregnancy, bleeding disorders, and uncontrolled urinary tract infections. Flexible ureteroscopy can be one of the options for lower pole stones between 1.5 and 2 cm in size. This option should be exercised in cases of difficult lower polar anatomy and ESWL-resistant stones. Flexible ureteroscopy can also be an option for stones located in the diverticular neck or a diverticulum. ESWL is the treatment to be discussed as a option in all patient with renal stones (excluding lower polar stones) between size 10 and 20 mm. In addition, in lower polar stones of size between 10 and 20 mm if the anatomy is favourable, ESWL is the option. In proximal ureteral stones, ESWL should be considered as a option with flexible ureteroscopy Active monitoring has a limited role and can be employed in post-intervention (PCNL or ESWL) residual stones, in addition, asymptomatic patients with no evidence of infection and fragments less than 4 mm can be monitored actively.

Kinetics of fertilization and development, and sex ratio of bovine embryos produced using the semen of different bulls

The between bulls variation in in vitro fertility and the shift of sex ratio towards male embryos are two problems affecting the in vitro production (IVP) of bovine embryos. Our objective was to evaluate the kinetics of fertilization, embryo development and the sex ratio of the resulting embryos using the frozen/thawed semen of four different bulls. In a first experiment, the kinetics of pronucleus (PN) formation was evaluated at 8, 12 and 18 h post-insemination (hpi). Based upon the pronuclei sizes and the distance between the two pronuclei, inseminated oocytes were classified in three PN stages. Differences between bulls were observed at each time point, but were more important at 12 hpi. At 8 and 12 hpi bull III showed a significantly faster PN evolution by comparison with the three other bulls (P<0.05), while at 18 hpi, the proportion of the three PN stages was similar to those of bulls I and IV, bull II being delayed. In a second experiment, the kinetics of in vitro embryo development was compared using time-lapse cinematography. The analysis of embryos reaching the blastocyst stage revealed significant differences in the mean time of first cleavage (range of 22.7-25.6h, P<0.05), while the lengths of the subsequent three cell cycles did not differ between bulls. The early mean time of first cleavage with bull III was associated with an early blastulation and a high blastocyst rate at Day 7, in opposition to what was observed with bull II showing a later timing of first cleavage (first cleavage 22.1 hpi versus 25.5 hpi; blastulation 140.4 hpi versus 152.5 hpi; D7 blastocyst rates: 31.3% versus 21.9%; P<0.05). In a third experiment, 65-76 Day 8 blastocysts per bull were sexed by PCR. Only blastocysts obtained with bull III showed a shift in sex ratio towards male embryos (76% male embryos; P<0.05). Such shift was already observed at the 2-cell and morula stages. In conclusion, the bull influences the kinetics of PN formation, of embryo development and the sex ratio of the embryos. Moreover, those parameters might be related.

Assessment of sperm quality parameters of six bulls showing different abilities to promote embryo development in vitro

Experiments were conducted to investigate the possible origins of variation between six bulls showing various blastocyst rates after in vitro fertilisation. No significant difference was observed for the rates of cleavage and 5-8 cell stages, whereas blastocyst yields at Day 6, 7 and 8 post insemination were significantly different between bulls (P < 0.05). Fertilisation rates ranged from 59.5 to 79.3% (P < 0.05), with no difference in the incidence of polyspermy. The proportions of motile and progressive spermatozoa before and after Percoll separation were analysed. A positive effect of Percoll was noted on both parameters (P < 0.05), leading to the absence of difference between bulls after the separation process. Sperm viability and spontaneous acrosome reaction were assessed during 18 h incubation in fertilisation medium. A sharp decrease in sperm viability was observed for all bulls after 2 h incubation, with only 12.6-21.7% of spermatozoa still viable at 18 h. In contrast, the proportion of reacted acrosomes was low in five out of six bulls (<15% at 18 h). In conclusion, the fertilisation rate was the only parameter to show some correlation with blastocyst rate for all bulls.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones

BACKGROUND

Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide.

OBJECTIVE

To develop recommendations for RIRS on the basis of existing data and expert consensus.

DESIGN, SETTING, AND PARTICIPANTS

A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%.

RESULTS AND LIMITATIONS

The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed.

CONCLUSIONS

The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting.

PATIENT SUMMARY

An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.

Minimally invasive surgery for the treatment of ureteral stump syndrome

OBJECTIVE

The aim was to highlight the advantages and the feasibility of treating ureteral stump syndrome (USS) by different minimally invasive procedures.

MATERIALS AND METHODS

Four patients with USS who were treated by different minimally invasive surgery approaches depending on their presentation and findings on radiologic investigations.

RESULTS

Three patients had complete resolution of their symptoms, whereas the fourth patient had persistence of urinary tract infection.

CONCLUSION

Minimally invasive surgery is a valid treatment option for patients with USS with possible less morbidity than conventional open surgical excision.

TMS as tool to investigate the effect of pharmacological medications on cortical plasticity

The application of medications with a well-defined mode of action on a neurotransmitter or neuromodulator of the central nervous system (CNS) can be utilized to test the pharmaco-physiological properties of transcranial magnetic stimulation (TMS) on cortical excitability and plasticity. Similarly, a physiologically well-defined TMS measure of cortical excitability may be exploited to study a particular drug's effect at the level of the cerebrum. In this review, we aim to assess the impact of calcium channel blockers, Selective Serotonin Reuptake Inhibitors (SSRIs), and GABAergic agents on cortical excitability and plasticity while concurrently investigating how TMS can enhance this understanding. We will begin by reviewing the basics of neuroplasticity, as explored in animal experimentation, and relate this to our knowledge about neuroplasticity induced in humans by TMS techniques. We will then discuss pharmacological modulation of plasticity in humans. Finally, we will review abnormalities of plasticity inherent to certain neuropsychiatric diseases and discuss how the combination of TMS with pharmacological intervention can augment our knowledge of the pathophysiology of these diseases and guide purposeful treatment.

Computed tomography-guided transgluteal percutaneous nephrolithotripsy in an ectopic pelvic kidney: novel technique

BACKGROUND AND PURPOSE

Management of stones in the ectopic pelvic kidney can be very challenging. Treatment of each patient should be individualized. We describe a new approach that is CT-guided transgluteal percutaneous nephrolithotripsy (PCNL).

CASE AND TECHNIQUE

A 19-year-old male presented with symptomatic right ectopic pelvic kidney stones. He was treated with CT-guided transgluteal PCNL. The patient was stone free at postoperative day 1. No major complications were observed, and the patient was discharged home on postoperative day 2.

CONCLUSION

CT-guided transgluteal PCNL is a safe and effective option for selected patients with ectopic pelvic kidney stones.

Pfannenstiel incision for intact specimen extraction in laparoscopic transperitoneal radical nephrectomy: a longitudinal prospective outcome study

OBJECTIVES

To evaluate the intra- and postoperative outcomes of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel transverse suprapubic incision.

METHODS

Prospective follow-up of 26 laparoscopic transperitoneal radical nephrectomies for suspected renal tumors in which the kidneys were extracted via a Pfannenstiel lower abdominal transverse incision.

RESULTS

The mean operating time was 152.3 (80-255) minutes, and the mean blood loss was 90 (20-300) ml. The mean extraction time was 20.4 (12-35) minutes. The mean weight of the removed specimen was 631.5 (190-1505) grams, and the mean longest diameter of the extracted specimen was 17.4 (9-25) cm. The mean extraction incision size was 10.7 (7-16) cm. No open surgical conversions were necessary. Pain control was excellent, with minimal intravenous morphine equivalent narcotic use by patients: 15.7 (0-31) mg in the recovery room, 33.8 (0-127) mg on the first postoperative day and 8.7 (0-60) mg in the first week after discharge. The patients experienced a short duration to full ambulation and normal dietary intake. Postoperative follow-up visits were recorded for at least six months. The patients reported a high cosmetic satisfaction rate of 97.7% (60-100). No late postoperative complications were observed related to the extraction site.

CONCLUSIONS

The operative specimen can be extracted via a low transverse Pfannenstiel incision during radical laparoscopic nephrectomy. This incision ensures the extraction of large specimens while preserving the aesthetic and functional advantages of laparoscopy without increasing the cancer risk. The absence of muscle cutting maintains the integrity of the abdominal wall and elicits minimal pain. No postoperative incisional hernias or keloid formations were observed.

A Staghorn Calcium Phosphate Stone in a Child With Sanjad-Sakati Syndrome: An Iatrogenic Manifestation?

Sanjad-Sakati syndrome (SSS) is an autosomal recessive genetic condition, with the first report discussing this condition presented in Saudi Arabia. This case report describes an iatrogenic stone as a result of hypocalcemia overtreatment, along with its subsequent management procedure. The current literature concerning the iatrogenic stone occurrence and the operative outcome of percutaneous nephrolithotomy in individuals with SS is scarce, warranting further investigation.

Giant staghorn stone causing inferior vena cava compression: a novel case report

Staghorn calculi (SC) are defined as large kidney stones that fill the renal pelvis and at least one renal calyx. They represent 10-20% of all renal stones in developing countries and require prompt diagnosis and management. Massive SC (over 5 cm) are treated exclusively via open surgery, despite percutaneous nephrolithotomy (PCNL) being the gold standard treatment for large stones. Descriptions of PCNL for massive SC are very limited in the literature.

Case Presentation

We report a case of a 63-year-old male who presented with chronic abdominal pain, hepatosplenomegaly, and normal renal function. He was later diagnosed with polycythemia vera. Computed tomography of the abdomen revealed massive, bilateral staghorn stones measuring 7.3×5.5 cm and 1.8×4.5 cm on the right and left, respectively. Additionally, the right stone was found to be compressing the inferior vena cava (IVC). The patient was promptly scheduled for right-sided PCNL and the target of 80% stone fragmentation was successfully attained.

Discussion

We present the first case of a stone of such size in the Middle East, as well as the first known case of a renal stone compressing the IVC. Unlike previous reports, the stone was successfully fragmented via PCNL - a procedure that has not been described for stones of such size.

Conclusion

This report highlights that ultrasound-guided PNCL without any other intervention is sufficient for the successful treatment of giant SC. Greater research is needed on the potential utility of using ultrasound-guided PCNL for the fragmentation of stones sized over 5 cm.

A unique case of enteric duplication cyst in a neonate: A case report study

INTRODUCTION

Clinical manifestations of intestinal duplication cysts are varied, influenced by factors such as size, location, and mass effect. Most of these cysts are adjacent to the second or third portion of the native duodenum. Complete surgical excision is the standard treatment for symptomatic enteric duplication cysts.

CASE PRESENTATION

We present the case of a neonate who was admitted to the hospital with abdominal distension and jaundice. Abdominal ultrasound and CT scan revealed a cystic mass of uncertain origin. Surgical exploration demonstrated a duodenal duplication cyst, which was successfully excised. Histopathological examination confirmed the diagnosis. A review of the literature highlights the approach to duodenal duplication cysts in neonates.

CLINICAL DISCUSSION

While rare, duodenal duplication cysts should be considered in the differential diagnosis of abdominal masses. Comprehensive imaging studies and histopathological examination are essential for accurate diagnosis.

CONCLUSION

Complete surgical excision of duodenal duplication cysts is crucial to prevent potential complications, such as malignant transformation.

A unique case of a unicameral bone cyst in the femoral neck: Successful management in a 14-year-old male

INTRODUCTION

Unicameral bone cysts (UBCs) are benign bone lesions that may resemble tumors. The mechanism of their formation is not precisely known. They tend to manifest with pain in the area of the lesion, thinning of the adjacent bone cortex, and may lead to bone fractures.

CASE PRESENTATION

A 14-year-old boy presented with severe pain in the left hip joint area, which resulted in limping and a tendency to avoid weight-bearing on the affected limb due to the associated pain. He was diagnosed with a unicameral bone cyst and treated percutaneously with aspiration, bone compaction, and fixation.

CLINICAL DISCUSSION

Unicameral bone cysts, when located in the hip area, can cause severe pain, potentially leading to compensatory scoliosis and limping. Treatment is essential in this case due to the sensitivity of the area, the high probability of fracture, and the presence of severe pain.

CONCLUSION

This article focuses on a rare case of a unicameral bone cyst in the femoral neck area, successfully managed percutaneously without open surgical intervention. Prophylactic fixation of the femoral neck resulted in an excellent observed outcome.

Association Between Kidney Stone and Dental Calculus in a Saudi Population: A Cross-Sectional Study

OBJECTIVE

To investigate the correlation between dental calculus and kidney stones, and to identify the risk factors associated with the presence of these conditions.

METHODS

This study was carried out at the medical city, King Saud University, Riyadh, Saudi Arabia between 2020 and 2021. The study included 141 participants (70 with kidney stones and 71 with controls). The dental plaque and calculus indices were used to record plaque and calculus scores, respectively. All information was statistically investigated and the level of significance was set at p<0.05.

RESULTS

The plaque and calculus indices were significantly higher in the control group when compared to the kidney stone group (p<0.05). A weak positive correlation between age and the calculus index in the kidney stone group was revealed (r=0.31, p=0.01). However, only within the age group 36-55, the results showed that the control group had a significantly higher calculus index than that of the kidney stone group (p=0.02). The married patients with kidney stones scored a significantly higher plaque index than the unmarried patients (p=0.03).

CONCLUSION

The dental plaque and calculus indices were lower in the kidney stone group than those of the non-kidney stone group. Therefore, the clinical observation of dental plaque and calculus may not be indicators of kidney stones. However, within the kidney stone group, elderly and married patients could be at a higher risk for developing dental calculus and plaque, respectively.

Neurogenic Bladder-Induced Stone in a Pelvic Kidney of a Caudal Regression Syndrome Patient: Management of a Complex Case

Percutaneous nephrolithotomy (PCNL) is a difficult treatment for treating kidney stones, especially when there are orthopedic or skeletal abnormalities. Here, in a 19-year-old male, we describe a two-step PCNL with a case of caudal regression syndrome (CRS) and a pelvic kidney, with an extremely deformed neurogenic bladder on intermittent catheterization. Our conclusion is that PCNL may be done safely with minimum morbidity in patients with caudal regression syndrome by utilizing adult equipment for heavy stone burdens, allowing full and rapid stone removal.

Clinical Application of a Two-Step Percutaneous Nephrolithotomy in a Patient With Severe Kyphoscoliosis and a Malrotated Kidney

This case report describes a two-step percutaneous nephrolithotomy (PCNL) in a 22-year-old male who had severe kyphoscoliosis and a malrotated kidney. The operation was performed with the patient under general anesthesia and in the left lateral decubitus position. All stones were successfully removed. No complications occurred during surgery, and the patient recovered well. Regardless of the posed challenges for kidney stone treatment in patients with spinal deformities, PCNL is not only a minimally invasive but also a safe and effective treatment option when done under correct positioning. The success rate is high, and the morbidity rate is low. According to the literature, only 125 cases of PCNL implications in kyphoscoliosis patients have been reported in emerging case reports and case series.

The Saudi urological association guidelines on urolithiasis

Aims

The Saudi Urolithiasis Guidelines are a set of recommendations for diagnosing, evaluating, and treating urolithiasis in the Saudi population. These guidelines are based on the latest evidence and expert consensus to improve patient outcomes and optimize care delivery. They cover the various aspects of urolithiasis, including risk factors, diagnosis, medical and surgical treatments, and prevention strategies. By following these guidelines, health-care professionals can improve care quality for individuals with urolithiasis in Saudi Arabia.

Panel

The Saudi Urolithiasis Guidelines Panel consists of urologists specialized in endourology with expertise in urolithiasis and consultation with a guideline methodologist. All panelists involved in this document have submitted statements disclosing any potential conflicts of interest.

Methods

The Saudi Guidelines on Urolithiasis were developed by relying primarily on established international guidelines to adopt or adapt the most appropriate guidance for the Saudi context. When necessary, the panel modified the phrasing of recommendations from different sources to ensure consistency within the document. To address areas less well covered in existing guidelines, the panel conducted a directed literature search for high quality evidence published in English, including meta analyses, randomized controlled trials, and prospective nonrandomized comparative studies. The panel also searched for locally relevant studies containing information unique to the Saudi Arabian population. The recommendations are formulated with a direction and strength of recommendation based on GRADE terminology and interpretation while relying on existing summaries of evidence from the existing guidelines.