Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard

OBJECTIVES

A classification (modified Clavien system) has been proposed to grade perioperative complications. We reviewed our experience with percutaneous nephrolithotomy (PNL), grading the complications according to this new classification.

METHODS

A total of 811 PNLs were performed between 2003 and 2006, and charts were retrospectively reviewed focusing on complications observed. According to the modified Clavien classification system, perioperative complications were stratified into five grades. Grade 1 defined all events that, if left untreated, would have a spontaneous resolution or needed a simple bedside intervention. Grade 2 complications required specific medication, including antibiotics and blood transfusion. Grade 3 complications necessitated surgical, endoscopic, or radiologic intervention (3a without general anesthesia, 3b under general anesthesia). Neighboring organ injuries and organ failures were classified as grade 4, and death was considered a grade 5 complication. Kidney stones treated with PNL were also classified as simple and complex and complication rates were compared.

RESULTS

A total of 255 perioperative complications were observed in 237 (29.2%) patients. There were 33 grade 1 (4%), 132 grade 2 (16.3%), 54 grade 3a (6.6%), 23 grade 3b (2.8%), 9 grade 4a (1.1%), and 3 grade 4b (0.3%) complications, and 1 death (0.1%). Most complications were related to bleeding and urine leakage. Grade 2 and 3a complications were significantly more common in patients with complex renal stones.

CONCLUSIONS

A graded classification scheme for reporting the complications of PNL may be useful for monitoring and reporting outcomes. However, minor modifications concerning auxiliary treatments are needed and further studies are awaited.

Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study

INTRODUCTION

Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy.

METHODS

The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012.

RESULT

On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents.

CONCLUSION

Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

Evaluation of trends in urolith composition in cats: 5,230 cases (1985–2004)

OBJECTIVE

To determine trends in urolith composition in cats.

DESIGN

Retrospective case series.

SAMPLE POPULATION

5,230 uroliths.

PROCEDURES

The laboratory database for the Gerald V. Ling Urinary Stone Analysis Laboratory was searched for all urolith submissions from cats from 1985 through 2004. Submission forms were reviewed, and each cat's age, sex, breed, and stone location were recorded.

RESULTS

Minerals identified included struvite, calcium oxalate, urates, dried solidified blood, apatite, brushite, cystine, silica, potassium magnesium pyrophosphate, xanthine, and newberyite. During the past 20 years, the ratio of calcium oxalate stones to struvite stones increased significantly. When only the last 3 years of the study period were included, the percentage of struvite stones (44%) was higher than the percentage of calcium oxa-late stones (40%). The most common location for both types of uroliths was the bladder. The number of calcium oxalate-containing calculi in the upper portion of the urinary tract increased significantly during the study period. The number of apatite uroliths declined significantly and that of dried solidified blood stones increased significantly, compared with all other stone types. No significant difference in the number of urate stones was detected.

CONCLUSIONS AND CLINICAL RELEVANCE

The increasing proportion of calcium oxalate uroliths was in accordance with findings from other studies and could be a result of alterations in cats' diets. However, the decreased percentage of calcium oxalate calculi and increased percentage of struvite calculi observed in the last 3 years may portend a change in the frequency of this type of urolith.

International Alliance of Urolithiasis guideline on retrograde intrarenal surgery

OBJECTIVES

To set out the second in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis that concerns retrograde intrarenal surgery (RIRS), with the aim of providing a clinical framework for urologists performing RIRS.

MATERIALS AND METHODS

After a comprehensive search of RIRS-related literature published between 1 January 1964 and 1 October 2021 from the PubMed database, systematic review and assessment were performed to inform a series of recommendations, which were graded using modified GRADE methodology. Additionally, quality of evidence was classified using a modification of the Oxford Centre for Evidence-Based Medicine Levels of Evidence system. Finally, related comments were provided.

RESULTS

A total of 36 recommendations were developed and graded that covered the following topics: indications and contraindications; preoperative imaging; preoperative ureteric stenting; preoperative medications; peri-operative antibiotics; management of antithrombotic therapy; anaesthesia; patient positioning; equipment; lithotripsy; exit strategy; and complications.

CONCLUSION

The series of recommendations regarding RIRS, along with the related commentary and supporting documentation, offered here should help provide safe and effective performance of RIRS.

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

OBJECTIVE

To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy.

METHODS

Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis.

RESULTS

A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy.

CONCLUSIONS

Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.

Duration of Follow-up and Timing of Discharge from Imaging Follow-up, in Adult Patients with Urolithiasis After Surgical or Medical Intervention: A Systematic Review and Meta-analysis from the European Association of Urology Guideline Panel on Urolithiasis

CONTEXT

No algorithm exists for structured follow-up of urolithiasis patients.

OBJECTIVE

To provide a discharge time point during follow-up of urolithiasis patients after treatment.

EVIDENCE ACQUISITION

We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library, clinicaltrials.gov, and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Fifty studies were eligible.

EVIDENCE SYNTHESIS

From a pooled analysis of 5467 stone-free patients, we estimated that for a safety margin of 80% for remaining stone free, patients should be followed up using imaging, for at least 2 yr (radiopaque stones) or 3 yr (radiolucent stones) before being discharged. Patients should be discharged after 5 yr of no recurrence with a safety margin of 90%. Regarding residual disease, patients with fragments ≤4 mm could be offered surveillance up to 4 yr since intervention rates range between 17% and 29%, disease progression between 9% and 34%, and spontaneous passage between 21% and 34% at 49 mo. Patients with larger residual fragments should be offered further definitive intervention since intervention rates are high (24-100%). Insufficient data exist for high-risk patients, but the current literature dictates that patients who are adherent to targeted medical treatment seem to experience less stone growth or regrowth of residual fragments, and may be discharged after 36-48 mo of nonprogressive disease on imaging.

CONCLUSIONS

This systematic review and meta-analysis indicates that stone-free patients with radiopaque or radiolucent stones should be followed up to 2 or 3 yr, respectively. In patients with residual fragments ≤4 mm, surveillance or intervention can be advised according to patient preferences and characteristics, while for those with larger residual fragments, reintervention should be scheduled.

PATIENT SUMMARY

Here, we review the literature regarding follow-up of urolithiasis patients. Patients who have no stones after treatment should be seen up to 2-3 yr, those with large fragments should be reoperated, and those with small fragments could be offered surveillance with imaging.

Ureteral stricture rate after endoscopic treatments for urolithiasis and related risk factors: systematic review and meta-analysis

PURPOSE

We aimed to accurately determine ureteral stricture (US) rates following urolithiasis treatments and their related risk factors.

METHODS

We conducted a systematic review and meta-analysis following the PRISMA guidelines using databases from inception to November 2023. Studies were deemed eligible for analysis if they included ≥ 18 years old patients with urinary lithiasis (Patients) who were subjected to endoscopic treatment (Intervention) with ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or shock wave lithotripsy (SWL) (Comparator) to assess the incidence of US (Outcome) in prospective and retrospective studies (Study design).

RESULTS

A total of 43 studies were included. The pooled US rate was 1.3% post-SWL and 2.1% post-PCNL. The pooled rate of US post-URS was 1.9% but raised to 2.7% considering the last five years' studies and 4.9% if the stone was impacted. Moreover, the pooled US rate differed if follow-ups were under or over six months. Patients with proximal ureteral stone, preoperative hydronephrosis, intraoperative ureteral perforation, and impacted stones showed higher US risk post-endoscopic intervention with odds ratio of 1.6 (P = 0.05), 2.6 (P = 0.009), 7.1 (P < 0.001), and 7.47 (P = 0.003), respectively.

CONCLUSIONS

The overall US rate ranges from 0.3 to 4.9%, with an increasing trend in the last few years. It is influenced by type of treatment, stone location and impaction, preoperative hydronephrosis and intraoperative perforation. Future standardized reporting and prospective and more extended follow-up studies might contribute to a better understanding of US risks related to calculi treatment.

The impact of COVID-19 outbreak on urolithiasis emergency department admissions, hospitalizations and clinical management in central Italy: a multicentric analysis

INTRODUCTION AND OBJECTIVES

We aimed to evaluate how the corona virus disease of 2019 (COVID-19) outbreak influenced emergency department (ED) admissions for urolithiasis, hospitalizations and clinical management of the hospitalized patients.

PATIENTS AND METHODS

We conducted a multicentric retrospective analysis of ED admissions in three high volume urology departments (one directly involved in COVID-19 patients management and two not involved) in Rome - Italy between March and April 2020 and in the same period of 2019. Statistical analysis was conducted on the number of admissions for urolithiasis, rate of complications, hospitalization and the type of treatment received.

RESULTS

304 patients were included in the analysis. A significant reduction in the global number of patients admitted to ED for urolithiasis between 2019 and 2020 (48.8%) was noted. Moreover, regarding the choice of treatment of hospitalized patients, a statistically significant increase of stone removal procedures versus urinary drainage was reported in 2020 (p = 0.015).

CONCLUSIONS

During the COVID-19 pandemic in Rome there has been a significant reduction of emergency admissions for urolithiasis. Patients admitted to ED had more complications, more frequently need hospitalization and regarding clinical management early stone removal was preferred over urinary drainage only. All the urologists should be aware that in the next months they could face an increased number of admissions for urolithiasis and manage more complicated cases.

European Association of Urology and European Society for Paediatric Urology Guidelines on Paediatric Urinary Stone Disease

CONTEXT

Paediatric stone disease is an important clinically entity and management is often challenging. Although it is known that the condition is endemic in some geographic regions of the world, the global incidence is also increasing. Patient age and sex; the number, size, location, and composition of the stone; and the anatomy of the urinary tract are factors that need to be taken into consideration when choosing a treatment modality.

OBJECTIVE

To provide a general insight into the evaluation and management of urolithiasis in the paediatric population in the era of minimally invasive surgery.

EVIDENCE ACQUISITION

A nonsystematic review of the literature on management of paediatric urolithiasis was conducted with the aim of presenting the most suitable treatment modality for different scenarios.

EVIDENCE SYNTHESIS

Because of high recurrence rates, open surgical intervention is not the first option for paediatric stone disease, except for very young patients with very large stones in association with congenital abnormalities. Minimally invasive surgeries have become the first option with the availability of appropriately sized instruments and accumulating experience. Extracorporeal shockwave lithotripsy (SWL) is noninvasive and can be carried out as an outpatient procedure under sedation, and is the initial choice for management of smaller stones. However, for larger stones, SWL has lower stone-free rates and higher retreatment rates, so minimally invasive endourology procedures such as percutaneous nephrolithotomy and retrograde intrarenal surgery are preferred treatment options.

CONCLUSIONS

Contemporary surgical treatment for paediatric urolithiasis typically uses minimally invasive modalities. Open surgery is very rarely indicated.

PATIENT SUMMARY

Cases of urinary stones in children are increasing. Minimally invasive surgery can achieve high stone-free rates with low complication rates. After stone removal, metabolic evaluation is strongly recommended so that medical treatment for any underlying metabolic abnormality can be given. Regular follow-up with imaging such as ultrasound is required because of the high recurrence rates.

The role of ureteroscopy in pediatric urology

PURPOSE OF REVIEW

Endoscopic evaluation and management of the diverse conditions involving the upper urinary tract using rigid or flexible endoscopes is now readily feasible and has been shown to be safe and efficacious even in the smallest children.

RECENT FINDINGS

Reduction in the size of the endoscopes, improvements in electronic imaging systems, proliferation of ancillary equipment, and improvement in endourologic skills among pediatric urologists make endoscopic treatment of pediatric urolithiasis the treatment of choice. The safety and efficacy of holmium:YAG laser lithotripsy make it the intracorporeal lithotriptor of choice. Successful outcomes can be obtained for ureteral and renal calculi that are similar to the adult population. Endoscopic treatment can be effective in highly selected children with intraluminal ureteral obstruction in the hands of a very experienced endoscopic pediatric urologist. These conditions include renal hemangiomas or arteriovenous malformations, ureteropelvic junction obstruction, ureteral strictures, or ureteral polyps.

SUMMARY

Pediatric ureteroscopic procedures are similar to their adult counterparts, in that basic endoscopic principles should be observed. Nevertheless, children pose specific technical challenges that require planning before endoscopy and that affect the risks and outcomes of these procedures. Future improvements in ureteroscopy will rely on the continued application of the new technology.

Minimally invasive surgical tube cystotomy for treating obstructive urolithiasis in small ruminants with an intact urinary bladder

Ten young, male, entire small ruminants (seven kids and three lambs) with obstructive urolithiasis, which were presented within three days of complete blockage and before rupture of the urinary bladder and urethra, underwent a minimally invasive surgical tube cystotomy through the left paralumbar fossa. The catheter was placed in the bladder lumen through a metallic cannula and fixed to the skin with a stay suture. Surgery was performed with the animal standing (six cases) or in right lateral recumbency (four cases) on the day of presentation. All animals were discharged the same day. Eight animals urinated normally within a mean of seven days (range four to 10 days). One animal had a blockage of urine flow as a result of kinking of the catheter on the third postoperative day, and in another the catheter collapsed on the fourth postoperative day. These were managed by a second, conventional surgical tube cystotomy. No recurrence of the condition was noticed in any of the animals during a six-month follow-up period.

An international delphi survey and consensus meeting to define the risk factors for ureteral stricture after endoscopic treatment for urolithiasis

PURPOSE

Iatrogenic ureteral strictures (US) after endoscopic treatment for urolithiasis represent a significant healthcare concern. However, high-quality evidence on the risk factors associated with US is currently lacking. We aimed to develop a consensus statement addressing the definition, risk factors, and follow-up management of iatrogenic US after endoscopic treatment for urolithiasis.

METHODS

Utilizing a modified Delphi method, a steering committee developed survey statements based on a systematic literature review. Then, a two-round online survey was submitted to 25 experts, offering voting options to assess agreement levels. A consensus panel meeting was held for unresolved statements. The predetermined consensus threshold was set at 70%.

RESULTS

The steering committee formulated 73 statements. In the initial survey, consensus was reached on 56 (77%) statements. Following in-depth discussions and refinement of 17 (23%) statements in a consensus meeting, the second survey achieved consensus on 63 (86%) statements. This process underscored agreement on pivotal factors influencing US in endoscopic urolithiasis treatments.

CONCLUSIONS

This study provides a comprehensive list of categorized risk factors for US following endoscopic urolithiasis treatments. The objectives include enhancing uniformity in research, minimizing redundancy in outcome assessments, and effectively addressing risk factors associated with US. These findings are crucial for designing future clinical trials and guiding endoscopic surgeons in mitigating the risk of US.

Comparison among the available stone treatment techniques from the first European Association of Urology Section of Urolithiasis (EULIS) Survey: Do we have a Queen?

PURPOSE

The miniaturization of instruments has had an impact on stone management. The aims of this study were to highlight surgeon preferences among Retrograde Intra Renal Surgery (RIRS), Regular, Mini-, UltraMini- and Micro- Percutaneous Nephrolithotomy (PCNL) for urolithiasis and to compare the effectiveness and safety of these techniques in a real-life setting.

METHODS

A 12-item survey regarding endourological techniques was conducted through Survey Monkey among attendees of the 2013 European Association of Urology Section of Urolithiasis meeting. We asked responders to share data from the last 5 cases they performed for each technique. Procedures were stratified according to stone size and the centres' surgical volume. Techniques were compared in terms of effectiveness and safety. Analyses were performed on the overall group and a subgroup of 1-2 cm stones.

RESULTS

We collected data from a total of 420 procedures by 30, out of 78, urologists who received the survey (response rate 38%): 140 RIRS, 141 Regular-PCNL (>20 Ch), 67 Mini-PCNL (14-20 Ch), 28 UltraMini-PCNL (11-13 Ch) and 44 Micro-PCNL (4,8-8 Ch). Techniques choice was influenced by stone size and the centre's surgical volume. Effectiveness and safety outcomes were influenced by stone size, independently of the technique. The stone-free rate was significantly lower in Micro-PCNL compared to Regular-PCNL. This was not confirmed for 1-2 cm stones. All techniques presented a lower complication rate than Regular-PCNL, with Mini-PCNL being the most protective technique compared to Regular-PCNL.

CONCLUSIONS

Stone size seems to drive treatment choice. Miniaturized PCNL techniques are widely employed for 1-2 cm stones, in particular in higher surgical volume centres. Mini-PCNL and RIRS are growing in popularity for stones > 2 cm. Mini-PCNL seems to be a good compromise, being the most effective and safe procedure among PCNL techniques. RIRS is characterized by satisfactory stone-free and low complication rates.

Changing practice locations for upper urinary tract stone disease

PURPOSE

Complex surgical procedures are migrating out of hospitals and into ambulatory surgery centers. We evaluated the extent to which surgery for urolithiasis could be a candidate for such migration.

MATERIALS AND METHODS

Patients undergoing stone surgery in Florida (107,417) between 1998 and 2004 were included in the study. Poisson models were fit to assess temporal changes in the setting (inpatient, outpatient and ambulatory surgery center) and type (open, percutaneous, extracorporeal, ureteroscopy and stenting) of stone surgery. For inpatient procedures secular trends in comorbidity burden (0 or 1 diagnoses vs 2 or more) and procedure acuity (elective vs emergency) were also assessed. Admission requirements and mortality rates were measured according to the surgery setting.

RESULTS

Of the 107,417 discharges from 1998 to 2004 surgery rates per 100,000 increased from 35.5 to 38.2 for inpatients (p <0.05), 84.2 to 104.7 for hospital outpatients (p <0.01) and 9.4 to 26.9 for ambulatory surgery centers (p <0.01). For hospitalized patients routine admissions decreased (41.8% to 29.5%, p <0.01) and procedure acuity increased (16.8% to 28.2%, p <0.01). No deaths occurred at ambulatory surgery centers and the rate of admission to acute care hospitals was 2.5/100,000 cases.

CONCLUSIONS

Despite the safety and efficiency of ambulatory surgery centers hospital outpatient departments remain the preferred setting for urinary stone surgery. For patients requiring surgical intervention for urinary stone disease ambulatory surgery centers could be an underused resource.

Clinical practice: surgical approaches to urolithiasis in children

The incidence of urolithiasis in children is increasing. Adequate knowledge of treatment modalities and surgical options is therefore essential for every pediatrician. Surgical approaches to urolithiasis in children continue to evolve with advancements in technology and sophistication of current equipment and techniques. Perhaps the most significant development in new techniques is the advent of robotic-assisted laparoscopy. This review, for the general pediatrician, summarizes the most recent pediatric data and guidelines for surgical approaches to treatment of urolithiasis.

Transurethral Cystoscopy and Endoscopic Urolith Removal in Female Guinea Pigs (Cavia porcellus)

Urinary diseases are commonly found in guinea pigs. Diagnostic workup includes clinical examination, blood testing, imaging studies, urine culture, and urinalysis. This article describes the use of transurethral cystoscopy in female guinea pigs as an ancillary tool to diagnose abnormalities within the bladder and urethra. In addition, the transurethral cystoscopic removal of uroliths measuring up to 5 mm and situated within the urinary bladder is described.

Uroliths composed of antiviral compound GS-441524 in 2 cats undergoing treatment for feline infectious peritonitis

Feline infectious peritonitis (FIP) historically has been a fatal disease in cats. Recent unlicensed use of antiviral medication has been shown to markedly improve survival of this infection. An 8-month-old female spayed domestic short-haired cat undergoing treatment for presumptive FIP with the antiviral nucleoside analog GS-441524 developed acute progressive azotemia. Abdominal ultrasound examination identified multifocal urolithiasis including renal, ureteral, and cystic calculi. Unilateral ureteral obstruction progressed to suspected bilateral ureteral obstruction and subcutaneous ureteral bypass (SUB) was performed along with urolith removal and submission for analysis. A 2-year-old male neutered domestic medium-haired cat undergoing treatment for confirmed FIP with GS-441524 developed dysuria (weak urine stream, urinary incontinence, and difficulty expressing the urinary bladder). This cat also was diagnosed sonographically with multifocal urolithiasis requiring temporary tube cystostomy after cystotomy and urolith removal. In both cases, initial urolith analysis showed unidentified material. Additional testing confirmed the calculi in both cats to be 98% consistent with GS-441524. Additional clinical studies are required to determine best screening practices for cats presented for urolithiasis during treatment with GS-441524.

A randomized clinical trial evaluating the short-term results of ureteral stent encrustation in urolithiasis patients undergoing ureteroscopy: micro-computed tomography evaluation

Although many ureteral stents are commercially available, the actuality of encrustation is yet to be elucidated in humans. This study compared the Tria Ureteral Stent with PercuShield and the Polaris Ultra Ureteral Stent with HydroPlus Coating for short-term encrustation formation. Eighty-four patients, who required ureteral stent placement after ureteroscopy, were randomized into two stent groups. After stent removal on postoperative day 14, the encrustation volume on the stent surface was measured by micro-computed tomography. The primary outcome was the inner luminal encrustation volume. Secondary outcomes were encrustation volume on the outer or total surfaces and occurrence of adverse events. Clinical factors related to encrustation were also assessed as a post-hoc analysis. Finally, of the 82 patients analyzed, 75 (91.5%) had encrustation in the inner lumen of the stent. The difference in median inner encrustation volume between the Tria and Polaris Ultra stents was comparable (0.56 vs. 0.37 mm3, P = 0.183). There was no difference observed in the encrustation volume on the outer/total surfaces and stent-related adverse events. In both ureteral stents, the shaft body showed significant inner luminal encrustation compared to the proximal or distal loop (all, P < 0.05). Dyslipidemia (P = 0.027), elevated urine pH (P = 0.046), and crystalluria (P = 0.010) were associated with encrustation formation. The Tria and Polaris Ultra stents had similar efficacy for preventing encrustation in the short-term. Further studies are required to compare their long-term patency.

Comparative risk of chronic kidney diseases in patients with urolithiasis and urological interventions: a longitudinal population-based study

Large cohort studies on whether any association existed between urological interventions for urolithiasis and the development of CKD are lacking. From claims data of the National Health Insurance (NHI) program of Taiwan, we identified 54,433 patients newly diagnosed with urolithiasis during 1998-2010. For each case, four individuals without urolithiasis were randomly selected and frequency matched by age, sex, and diagnosis year. Both groups were followed up until the end of 2010. Incident CKD events were identified by the International Classification of Diseases, Ninth Revision (ICD-9) code in the NHI registration database. The overall incidence of periodontal diseases was 1.85-fold greater in the urolithiasis group than in the comparison group (33.9 vs 18.3 per 10,000 person-years; 95 % confidence interval [CI] 1.81-1.90). Compared with the adjusted hazard ratios (aHRs) of nonurolithiasis patients, those of patients with urolithiasis increased with the number of medical visits (from 0.91 [95 % CI 0.83-1.00] to 10.6 [95 % CI 9.48-11.8]) and urological interventions (from 1.22 [95 % CI 1.10-1.35] to 86.4 [95 % CI 67.6-110.6]). The aHR was similar in different urological intervention methods, extracorporeal shock wave lithotripsy, ureteroscopy, percutaneous nephrostolithotomy, and open stone surgery. The urological intervention for urolithiasis is associated with an increased risk of CKD. We should be aware of the risk for CKD, especially in patients who have received multiple urological interventions and those elderly.

Outcomes of ureteroscopy and internal ureteral stent for pregnancy with urolithiasis: a systematic review and meta-analysis

OBJECTIVES

To investigate the outcomes of internal ureteral stents in comparison with ureteroscopy (URS) for pregnant women with urolithiasis.

DATA SOURCES

Relevant studies published from January 1980 to June 2022 were identified through systematic literature searches of MEDLINE, EMBASE, Web of Science and the Cochrane Library.

METHODS OF STUDY SELECTION

A total of 499 studies were initially identified. We included pregnant women in any stages of gestation who underwent double-J (D-J) stent insertion only or ureteroscopy for the treatment of urolithiasis; for a study to be included, the number of participants needed to exceed 10. This systematic review was registered on the PROSPERO website (Reference: CRD42020195607).

RESULTS

A total of 25 studies were identified with 131 cases undergoing serial stenting and 789 cases undergoing URS. The pooled operative success rate was 97% for D-J stent insertion and 99% for URS. Only a few patients passed stones spontaneously after serial D-J stenting. The pooled stone free rate (SFR) in URS operations was about 91%. For internal ureteral stent therapy, the rate of normal fertility outcomes was 99%, although the pooled incidence of complications was approximately 45%. For group receiving URS treatment, the rate of normal fertility outcome was 99% and the pooled incidence of complications was approximately 1%. However, the pooled rate of premature birth and abortion were the similar between the two groups (< 1%); the rate of serious complications was also similar between the two groups.

CONCLUSIONS

Although internal ureteral stents may cause more minor complications, both ureteroscopy and internal ureteral stents showed had low rates of adverse effects on fertility outcomes when used to treat pregnant women with symptomatic urolithiasis. Evidence suggests that URS may have a greater advantage for pregnant patients with urinary stones when conditions permit. Since, it has been proven to be safe and effective, internal ureteral stents could be considered in emergency or other special situations.

Experts' recommendations in laser use for the treatment of urolithiasis: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group

PURPOSE

To identify laser lithotripsy settings used by experts for specific clinical scenarios and to identify preventive measures to reduce complications.

METHODS

After literature research to identify relevant questions, a survey was conducted and sent to laser experts. Participants were asked for preferred laser settings during specific clinical lithotripsy scenarios. Different settings were compared for the reported laser types, and common settings and preventive measures were identified.

RESULTS

Twenty-six laser experts fully returned the survey. Holmium-yttrium-aluminum-garnet (Ho:YAG) was the primary laser used (88%), followed by thulium fiber laser (TFL) (42%) and pulsed thulium-yttrium-aluminum-garnet (Tm:YAG) (23%). For most scenarios, we could not identify relevant differences among laser settings. However, the laser power was significantly different for middle-ureteral (p = 0.027), pelvic (p = 0.047), and lower pole stone (p = 0.018) lithotripsy. Fragmentation or a combined fragmentation with dusting was more common for Ho:YAG and pulsed Tm:YAG lasers, whereas dusting or a combination of dusting and fragmentation was more common for TFL lasers. Experts prefer long pulse modes for Ho:YAG lasers to short pulse modes for TFL lasers. Thermal injury due to temperature development during lithotripsy is seriously considered by experts, with preventive measures applied routinely.

CONCLUSIONS

Laser settings do not vary significantly between commonly used lasers for lithotripsy. Lithotripsy techniques and settings mainly depend on the generated laser pulse's and generator settings' physical characteristics. Preventive measures such as maximum power limits, intermittent laser activation, and ureteral access sheaths are commonly used by experts to decrease thermal injury-caused complications.

Urothelial dysfunction and increased suburothelial inflammation of urinary bladder are involved in patients with upper urinary tract urolithiasis--clinical and immunohistochemistry study

Objectives

To investigate the urothelial dysfunction and inflammation of urinary bladder in patients with upper urinary tract (UUT) urolithiasis through the results of cystoscopic hydrodistension and immunohistochemistry study.

Methods

Ninety-one patients with UUT urolithiasis underwent cystoscopic hydrodistension before the stone surgery. Immunofluorescence staining of E-cadherin, zonula occludens-1 (ZO-1), tryptase (mast cell activation), and TUNEL (urothelial apoptosis) were performed in 42 patients with glomerulations after hydrodistension, 10 without glomerulations, and 10 controls.

Results

Of the 91 patients, 62 (68.2%) developed glomerulations after hydrodistension. Lower urinary tract symptoms (LUTS) were present in 53.8% patients, in whom significantly smaller maximal anesthetic bladder capacity (MBC) was noted. Patients with middle or lower 1/3 ureteral stones had a significantly higher glomerulation rate (88.6% vs. 55.4%, p<0.01) and lower MBC (618.4±167.6 vs. 701.2±158.4 ml, p = 0.027) than those with upper 1/3 ureteral or renal stones. Patients with UUT urolithiasis had significantly lower expression of E-cadherin (26.2±14.8 vs. 42.4±16.7) and ZO-1 (5.16±4.02 vs. 11.02±5.66); and higher suburothelial mast cell (13.3±6.8 vs. 1.3±1.2) and apoptotic cell (2.6±2.5 vs. 0.1±0.3) numbers than in controls (all p<0.01).

Conclusions

Urothelial dysfunction and increased suburothelial inflammation and apoptosis are highly prevalent in the bladders of UUT urolithiasis patients, indicating inflammation cross-talk between UUT and urinary bladder. Patients with UUT urolithiaisis concomitant with LUTS had a smaller MBC, which may explain the presence of irritative bladder symptoms.

Technique, complications, and outcomes of pediatric urolithiasis management at a tertiary care hospital: evolving paradigms over the last 15 years

BACKGROUND

Despite technological advancements, there is lack of consensus for the standard treatment modalities for pediatric urolithiasis.

OBJECTIVE

The primary objective was to review the management of pediatric urolithiasis over the last 15 years in terms of technical modifications, surgical outcomes, and complications. The secondary objective was to compare the efficacy and outcomes of standard percutaneous nephrolithotomy (PCNL) and mini-PCNL for renal and upper ureteric calculi.

STUDY DESIGN

Medical records of all patients aged <18 years who presented to the authors' tertiary care hospital in northern India between August 2003 and December 2018 were reviewed retrospectively. Before 2010, all PCNLs performed were standard PCNL, whereas after 2010, most PCNLs performed were mini-PCNL. Thus, the patients were divided into two groups: group A (patients up to 2010) and group B (patients after 2010). These were compared for the type of treatment, success rate, and complications. The outcomes of surgical management of lower ureteric and vesical calculi were also reviewed.

RESULTS

During this period, there were 580 children with urolithiasis (677 stone sites). There were 265 patients (321 stone sites) in group A and 315 patients (356 stone sites) in group B. The median age was seven years (range: 3-18 years). The most common location of calculus was the collecting system of the kidney (n = 398, 58.8%). A total of 175 stone sites (25.8%) were located in the ureter. Urinary bladder calculi were seen in 43 (6.4%) patients. Multiple stones were seen in 61 sites (9.0%). A total of 115 patients in group A underwent standard PCNL, whereas in group B, nine patients underwent standard PCNL and 129 underwent mini-PCNL. Group B had a significantly higher stone clearance rate for mini-PCNL (P < 0.001). Minor complications (grades 1 and 2) accounted for a majority of overall complications in both groups (87.5% in group A and 94.9% in group B).

DISCUSSION

Mini-PCNL is an excellent option for renal calculi in children as it offers dual advantages of improved stone clearance and reduced major complications such as bleeding. Ureteroscopic lithotripsy has been established as the standard for small lower ureteric calculi.

CONCLUSION

For renal and upper ureteric calculi, mini-PCNL has evolved as standard technique with a high stone-free rate and minimum complications compared with standard PCNL. Extracorporeal shockwave lithotripsy and ureteroscopic lithotripsy (URSL)/retrograde intrarenal surgery are acceptable alternatives for smaller stone burden. For lower ureteric and vesical calculi, retrograde approaches such as cystolithotripsy and URSL have now become the standard of care.