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王 明, 刘 军, 熊 六, 于 路, 胡 浩, 许 克, 徐 涛. [Efficacy and safety of mini-track, mini-nephroscopy and mini-ultrasonic probe percutaneous nephrolithotomy for the treatment of 1.5-2.5 cm kidney stones]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2024; 56:605-609. [PMID: 39041553 PMCID: PMC11284484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Indexed: 07/24/2024]
Abstract
OBJECTIVE To investigate the efficacy and safety of mini-track, mini-nephroscopy and mini-ultrasonic probe percutaneous nephrolithotomy (3mPCNL) for the treatment of 1.5-2.5 cm kidney stones. METHODS The perioperative data and postoperative follow-up data of a total of 25 patients with about 1.5-2.5 cm kidney stones who underwent 3mPCNL under ultrasound guidance in Peking University People's Hospital from November 2023 to January 2024 were retrospectively analyzed. During the matching period, the 25 patients with 1.5-2.5 cm kidney stones receiving standard percutaneous nephrolithotomy (sPCNL) were matched one-to-one according to the criterion that the absolute difference of the maximum diameter of stones between the two groups was less than 1 mm. The operative time, renal function changes, postoperative stone-free rate, hemoglobin changes, and complication rate of the two treatments were compared, and then the effectiveness and safety of 3mPCNL were preliminarily analyzed. RESULTS There were no significant differences in mean age, preoperative median creatinine, preoperative mean hemoglobin, preoperative mean hematocrit, median stone maximum diameter, and median stone CT density between the 3mPCNL group and the sPCNL group. The median operation time in the 3mPCNL group was 60.0 (45.0-110.0) min, with no statistical significance compared with the sPCNL group, and all the patients underwent single-channel operations. The mean hemoglobin after operation in the 3mPCNL group was (115.3±15.5) mmol/L, and there was no significant difference between the preoperative group and the sPCNL group, and the mean hemoglobin decreased significantly between the sPCNL group and the sPCNL group [(9.5±2.2) mmol/L vs. (10.1±1.9) mmol/L]. The mean hematocrit after operation was (28.0±5.2)%, and the difference was statistically significant compared with that before operation (t=2.414, P=0.020). The mean hematocrit drop was not statistically signi-ficant compared with the sPCNL group (2.3% vs. 2.7%). The median serum creatinine in the 3mPCNL group was 74.0 (51.0-118.0) μmol/L after operation, and the difference was statistically significant compared with that before operation (Z=-2.980, P=0.005). The stone-free rate in the 3mPCNL group and the sPCNL group was 96.0% and 97.3%, respectively, and the mean hospital stay was (4.3± 1.4) d and (5.5±2.0) d, respectively, with the statistical significance (t=0.192, P=0.025). After the operation, one patient in sPCNL group had massive hemorrhage after the nephrostomy tube was removed, which was improved after selective renal artery embolization. One patient in the 3mPCNL group developed mild perirenal hematoma, which was improved after conservative treatment, and no complications were observed in the other patients. CONCLUSION 3mPCNL in the treatment of 1.5-2.5 cm kidney stones can achieve an effective rate comparable to sPCNL, and can achieve the ideal stone-free rate in a shorter operative time with a lower rate of surgery-related complications.
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Affiliation(s)
- 明瑞 王
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 军 刘
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 六林 熊
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 路平 于
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 浩 胡
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 克新 许
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
| | - 涛 徐
- />北京大学人民医院泌尿外科,北京大学应用碎石技术研究所,北京 100044Department of Urology, Peking University People's Hospital; The Institute of Applied Lithotripsy Technology, Peking University, Beijing 100044, China
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Alzahrani MA, Alghuyaythat WKZ, Alsaadoon BMB, Aldahash AOA, Alghamdi AKM, Alshammary FMS, Alhodairy MSM, Alanazi AMA, Alotaibi BQ, Silsilah MAH, Alotibi ANA, Alhusini FKI, Alanazi TMA. Comparative efficacy of different surgical techniques for pediatric urolithiasis-a systematic review and meta-analysis. Transl Androl Urol 2024; 13:1127-1144. [PMID: 39100831 PMCID: PMC11291404 DOI: 10.21037/tau-23-676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 05/12/2024] [Indexed: 08/06/2024] Open
Abstract
Background Prior research has assessed a range of surgical treatments for pediatric urolithiasis, emphasizing the necessity of tailor-made therapeutic approaches. These studies also show the adaptability of percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and shock wave lithotripsy (SWL) in managing diverse stone dimensions. The goal of this research was to examine the effectiveness of these varying surgical methods in treating pediatric urolithiasis. Methods Seven digital databases were explored to gather pertinent studies, following the guidelines established by the PRISMA protocol. The retrieved studies were subsequently scrutinized to draw comparisons between the stone-free rate (SFR) and the rate of complications associated with PCNL, RIRS, and SWL. Results The SFR evaluation revealed no notable disparity between PCNL and RIRS [odds ratio (OR) 1.43, 95% confidence interval (CI): 0.67-3.05, P=0.36]. However, it was observed that both PCNL and RIRS outperformed SWL in terms of effectiveness (OR 2.51, 95% CI: 1.19-5.29, P=0.02 and OR 2.42, 95% CI: 1.41-4.14, P=0.001 respectively). Regarding the complication rates, no significant differences were observed among the three surgical methods (OR 0.67, 95% CI: 0.49-1.59, P=0.05), albeit with various forms of complications being reported. Certain studies associated PCNL with an elevated rate of complications, specifically urinary tract infections (UTIs) and severe hematuria. Conclusions Though PCNL and RIRS demonstrated higher effectiveness than SWL in achieving SFR, there was no significant disparity in the rates of complications across all three procedures. The study underscores the significance of personalized treatment plans, taking into account aspects such as the dimension and location of the stone, along with patient-specific characteristics.
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Affiliation(s)
- Meshari A. Alzahrani
- Department of Urology, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia
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Papatsoris A, Alba AB, Galán Llopis JA, Musafer MA, Alameedee M, Ather H, Caballero-Romeu JP, Costa-Bauzá A, Dellis A, El Howairis M, Gambaro G, Geavlete B, Halinski A, Hess B, Jaffry S, Kok D, Kouicem H, Llanes L, Lopez Martinez JM, Popov E, Rodgers A, Soria F, Stamatelou K, Trinchieri A, Tuerk C. Management of urinary stones: state of the art and future perspectives by experts in stone disease. Arch Ital Urol Androl 2024; 96:12703. [PMID: 38934520 DOI: 10.4081/aiua.2024.12703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
AIM To present state of the art on the management of urinary stones from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024. Options of treatment: The surgical treatment modalities of renal and ureteral stones are well defined by the guidelines of international societies, although for some index cases more alternative options are possible. For 1.5 cm renal stones, both m-PCNL and RIRS have proven to be valid treatment alternatives with comparable stone-free rates. The m-PCNL has proven to be more cost effective and requires a shorter operative time, while the RIRS has demonstrated lower morbidity in terms of blood loss and shorter recovery times. SWL has proven to be less effective at least for lower calyceal stones but has the highest safety profile. For a 6mm obstructing stone of the pelviureteric junction (PUJ) stone, SWL should be the first choice for a stone less than 1 cm, due to less invasiveness and lower risk of complications although it has a lower stone free-rate. RIRS has advantages in certain conditions such as anticoagulant treatment, obesity, or body deformity. Technical issues of the surgical procedures for stone removal: In patients receiving antithrombotic therapy, SWL, PCN and open surgery are at elevated risk of hemorrhage or perinephric hematoma. URS, is associated with less morbidity in these cases. An individualized combined evaluation of risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. Pre-interventional urine culture and antibiotic therapy are mandatory although UTI treatment is becoming more challenging due to increasing resistance to routinely applied antibiotics. The use of an intrarenal urine culture and stone culture is recommended to adapt antibiotic therapy in case of postoperative infectious complications. Measurements of temperature and pressure during RIRS are vital for ensuring patient safety and optimizing surgical outcomes although techniques of measurements and methods for data analysis are still to be refined. Ureteral stents were improved by the development of new biomaterials, new coatings, and new stent designs. Topics of current research are the development of drug eluting and bioresorbable stents. Complications of endoscopic treatment: PCNL is considered the most invasive surgical option. Fever and sepsis were observed in 11 and 0.5% and need for transfusion and embolization for bleeding in 7 and 0.4%. Major complications, as colonic, splenic, liver, gall bladder and bowel injuries are quite rare but are associated with significant morbidity. Ureteroscopy causes less complications, although some of them can be severe. They depend on high pressure in the urinary tract (sepsis or renal bleeding) or application of excessive force to the urinary tract (ureteral avulsion or stricture). Diagnostic work up: Genetic testing consents the diagnosis of monogenetic conditions causing stones. It should be carried out in children and in selected adults. In adults, monogenetic diseases can be diagnosed by systematic genetic testing in no more than 4%, when cystinuria, APRT deficiency, and xanthinuria are excluded. A reliable stone analysis by infrared spectroscopy or X-ray diffraction is mandatory and should be associated to examination of the stone under a stereomicroscope. The analysis of digital images of stones by deep convolutional neural networks in dry laboratory or during endoscopic examination could allow the classification of stones based on their color and texture. Scanning electron microscopy (SEM) in association with energy dispersive spectrometry (EDS) is another fundamental research tool for the study of kidney stones. The combination of metagenomic analysis using Next Generation Sequencing (NGS) techniques and the enhanced quantitative urine culture (EQUC) protocol can be used to evaluate the urobiome of renal stone formers. Twenty-four hour urine analysis has a place during patient evaluation together with repeated measurements of urinary pH with a digital pH meter. Urinary supersaturation is the most comprehensive physicochemical risk factor employed in urolithiasis research. Urinary macromolecules can act as both promoters or inhibitors of stone formation depending on the chemical composition of urine in which they are operating. At the moment, there are no clinical applications of macromolecules in stone management or prophylaxis. Patients should be evaluated for the association with systemic pathologies. PROPHYLAXIS Personalized medicine and public health interventions are complementary to prevent stone recurrence. Personalized medicine addresses a small part of stone patients with a high risk of recurrence and systemic complications requiring specific dietary and pharmacological treatment to prevent stone recurrence and complications of associated systemic diseases. The more numerous subjects who form one or a few stones during their entire lifespan should be treated by modifications of diet and lifestyle. Primary prevention by public health interventions is advisable to reduce prevalence of stones in the general population. Renal stone formers at "high-risk" for recurrence need early diagnosis to start specific treatment. Stone analysis allows the identification of most "high-risk" patients forming non-calcium stones: infection stones (struvite), uric acid and urates, cystine and other rare stones (dihydroxyadenine, xanthine). Patients at "high-risk" forming calcium stones require a more difficult diagnosis by clinical and laboratory evaluation. Particularly, patients with cystinuria and primary hyperoxaluria should be actively searched. FUTURE RESEARCH Application of Artificial Intelligence are promising for automated identification of ureteral stones on CT imaging, prediction of stone composition and 24-hour urinary risk factors by demographics and clinical parameters, assessment of stone composition by evaluation of endoscopic images and prediction of outcomes of stone treatments. The synergy between urologists, nephrologists, and scientists in basic kidney stone research will enhance the depth and breadth of investigations, leading to a more comprehensive understanding of kidney stone formation.
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Affiliation(s)
- Athanasios Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens; U-merge Scientific Office.
| | - Alberto Budia Alba
- Urology Department, La Fe University and Polytechnic Hospital, Valencia.
| | | | | | | | | | | | - Antònia Costa-Bauzá
- Laboratory of Renal Lithiasis Research, University Institute of Health Sciences Research (IUNICS-IdISBa), University of Illes Balears, Palma de Mallorca.
| | - Athanasios Dellis
- 2nd Department of Surgery, Aretaieion Academic Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens.
| | | | - Giovanni Gambaro
- Division of Nephrology, Department of Medicine, University Hospital of Verona.
| | - Bogdan Geavlete
- "Carol Davila" University of Medicine and Pharmacy & "Saint John" Emergency Clinical Hospital, Bucharest.
| | - Adam Halinski
- Private Medical Center "Klinika Wisniowa" Zielona Gora.
| | - Bernhard Hess
- Internal Medicine & Nephrology, KidneyStoneCenter Zurich, Klinik Im Park, Zurich.
| | | | - Dirk Kok
- Saelo Scientific Support, Oegstgeest.
| | | | - Luis Llanes
- Urology Department, University Hospital of Getafe, Getafe, Madrid.
| | | | - Elenko Popov
- Department of Urology, UMHAT "Tzaritza Yoanna-ISUL", Medical University, Sofia.
| | | | - Federico Soria
- Experimental Surgery Department, Ramón y Cajal University Hospital, Madrid.
| | - Kyriaki Stamatelou
- MESOGEIOS Nephrology Center, Haidari Attica and NEPHROS.EU Private Clinic, Athens.
| | | | - Christian Tuerk
- Urologic Department, Sisters of Charity Hospital and Urologic Praxis, Wien.
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Chen W, Hu H, Yu G. Percutaneous nephrolithotomy or flexible ureteral lithotripsy, which one is better for patients with upper ureteral calculi of 1.5-2.0 cm in diameter. BMC Urol 2024; 24:98. [PMID: 38664721 PMCID: PMC11044355 DOI: 10.1186/s12894-024-01480-1] [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: 01/19/2024] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
PURPOSE First research to evaluate the clinical efficacy and safety of flexible ureteral lithotripsy (FURSL) and percutaneous nephrolithotomy (PCNL) in the treatment of the upper ureteral stone is between 1.5 cm and 2.0 cm in diameter since there is no consensus with such ureteral stone yet. METHODS From December 2018 to October 2022, 104 patients with calculi in the upper ureter received percutaneous nephrolithotomy (PCNL)or flexible ureteroscopic lithotripsy (FURSL) in our institution. The clinical data of the patients in the two groups were retrospectively searched. Stone removal rate, operation time, blood loss, postoperative pain score, postoperative inflammatory factor, postoperative complication rates and ureteral obstruction three months after the operation were compared between the two groups. RESULTS A total of 104 patients were included in the study. The stone clearance rate and the secondary surgery rate were 88.89% and 7.41% in the FURSL group, the figures were 97.96% and 2.0% in the PCNL group (p = 0.067, 0.497). Regarding ureteral obstruction three months after the operation, there were 2 patients in FURSL group and 0 patients in PCNL group(p = 0.497).Compared to patients in FURSL group, patients in the PCNL group had shorter operation time(PCNL 71.81 ± 18.94 min vs. FURSL 86.80 ± 22.49 min, p = 0.0004), fewer complications(PCNL 20.37% vs. FURSL 6.12%), and lower postoperative inflammatory factor(p = 0.0004), yet they got more hemoglobin drop (PCNL 13.14 ± 9.81 g/L vs. FURSL 4.77 ± 3.55 g/L, p < 0.0001), higher postoperative pain scores(p = 0.0017) in the first three postoperative days and longer hospital stay (PCNL 4.96 ± 1.21 days vs. FURSL 3.60 ± 0.83 days). CONCLUSION Both FURSL and PCNL were effective methods for treating upper ureteral stones of 1.5-2.0 cm in diameter given the extremely high stone clearance rate and a very low secondary surgery rate, as long as rare ureteral obstruction in medium-long term observation. Additionally, FURSL can effectively reduce surgical bleeding, postoperative pain, and hospital stay, while PCNL can decrease operation time, the risk of infection, and complications. Therefore, doctors could select suitable surgical treatment for those patients depending on their different clinical situations based on these findings.
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Affiliation(s)
- Wenpu Chen
- Department of Urology, Jinshan District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences; Jinshan Branch of Shanghai Sixth People's Hospital, 147 Jiankang Road, Jinshan District, Shanghai, China
| | - Hengda Hu
- Department of Urology, Jinshan District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences; Jinshan Branch of Shanghai Sixth People's Hospital, 147 Jiankang Road, Jinshan District, Shanghai, China
| | - Guofeng Yu
- Department of Urology, Jinshan District Central Hospital affiliated to Shanghai University of Medicine & Health Sciences; Jinshan Branch of Shanghai Sixth People's Hospital, 147 Jiankang Road, Jinshan District, Shanghai, China.
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Abushamma F, Zyoud SH. Analyzing global research trends and focal points in the utilization of laser techniques for the treatment of urolithiasis from 1978 to 2022: visualization and bibliometric analysis. Urolithiasis 2024; 52:67. [PMID: 38630266 DOI: 10.1007/s00240-024-01568-1] [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: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
Laser lithotripsy is gaining global prominence and is a dynamically progressing field marked by a continual influx of new and comprehensive research each year. Recently, there has been a noticeable shift toward the adoption of various kinds of lasers, such as holmium: yttrium-aluminum-garnet (Ho:YAG) and thulium fiber (TFL) lasers. Consequently, we aim to conduct a bibliometric analysis to analyze key areas of research activity within scientific publications that center on the utilization of laser techniques in urolithiasis. A search of the literature spanning from 1978 to 2022 was carried out on 25 December 2023 using the Scopus database to explore research related to the application of laser techniques for urolithiasis treatment. Visualization analysis was performed using VOSviewer software (version 1.6.20). We examined 962 publications that met the specified criteria, 791 (82.22%) of which were original articles. The analysis of the retrieved publications indicated a consistent increase in research output from 1978 to 2022; a particularly noteworthy surge occurred after 2003. In particular, the U.S. claimed the leading position as the most productive country, contributing 211 articles (21.93%). However, India had the highest research productivity according to the adjustment index of 19.08. In the European region, 324 publications (33.68% of the total) originated from 25 countries. The Journal of Endourology contributed the most between 1978 and 2022 (n = 96, 9.98%). The most cited paper examined the effectiveness of holmium: yttrium-aluminum-garnet (Ho:YAG) lasers, while a subsequent study focused on the use of a thulium fiber laser (TFL), an emerging laser technology that has gained increased recognition. Co-occurrence analysis revealed three distinct clusters focusing on the types of laser technology, minimally invasive approaches, and success rate/postoperative complications. This comprehensive investigation delves into the global landscape of laser use for the treatment of urolithiasis. This review supports the emerging clinical concept of using various types of laser technology for urolithiasis treatment. Moreover, the hot issues that researchers should focus on based on the findings of this study are the use of different types of laser lithotripsy in view of the surgical approach, success rate and complications.
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Affiliation(s)
- Faris Abushamma
- Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine.
- Department of Urology, An-Najah National University Hospital, Nablus, 44839, Palestine.
| | - Sa'ed H Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine.
- Clinical Research Center, An-Najah National University Hospital, Nablus, 44839, Palestine.
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Meng R, Wang W, Zhai Z, Zuo C. Machine learning algorithm to predict postoperative bleeding complications after lateral decubitus percutaneous nephrolithotomy. Medicine (Baltimore) 2024; 103:e37050. [PMID: 38277513 PMCID: PMC10817089 DOI: 10.1097/md.0000000000037050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/03/2024] [Indexed: 01/28/2024] Open
Abstract
Bleeding is a serious complication following percutaneous nephrolithotomy (PCNL). This study establishes a predictive model based on machine learning algorithms to forecast the occurrence of postoperative bleeding complications in patients with renal and upper ureteral stones undergoing lateral decubitus PCNL. We retrospectively collected data from 356 patients with renal stones and upper ureteral stones who underwent lateral decubitus PCNL in the Department of Urology at Peking University First Hospital-Miyun Hospital, between January 2015 and August 2022. Among them, 290 patients had complete baseline data. The data was randomly divided into a training group (n = 232) and a test group (n = 58) in an 8:2 ratio. Predictive models were constructed using Logistic Regression, Random Forest, and Extreme Gradient Boosting (XGBoost). The performance of each model was evaluated using Accuracy, Precision, F1-Score, Receiver Operating Characteristic curves, and Area Under the Curve (AUC). Among the 290 patients, 35 (12.07%) experienced postoperative bleeding complications after lateral decubitus PCNL. Using postoperative bleeding as the outcome, the Logistic model achieved an accuracy of 73.2%, AUC of 0.605, and F1 score of 0.732. The Random Forest model achieved an accuracy of 74.5%, AUC of 0.679, and F1 score of 0.732. The XGBoost model achieved an accuracy of 68.3%, AUC of 0.513, and F1 score of 0.644. The predictive model for postoperative bleeding after lateral decubitus PCNL, established based on machine learning algorithms, is reasonably accurate. It can be utilized to predict postoperative stone residue and recurrence, aiding urologists in making appropriate treatment decisions.
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Affiliation(s)
- Rui Meng
- Department of Urology, YuQuan Hospital, Tsinghua University, Beijing, China
| | - Weining Wang
- Department of Urology, YuQuan Hospital, Tsinghua University, Beijing, China
| | - Zhipeng Zhai
- Department of Urology, YuQuan Hospital, Tsinghua University, Beijing, China
| | - Chao Zuo
- Department of Urology, Peking University First Hospital - Miyun Hospital, Beijing, China
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Soderberg L, Ergun O, Ding M, Parker R, Borofsky MS, Pais V, Dahm P. Percutaneous nephrolithotomy versus retrograde intrarenal surgery for treatment of renal stones in adults. Cochrane Database Syst Rev 2023; 11:CD013445. [PMID: 37955353 PMCID: PMC10642177 DOI: 10.1002/14651858.cd013445.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Kidney stones (also called renal stones) can be a source of pain, obstruction, and infection. Depending on size, location, composition, and other patient factors, the treatment of kidney stones can involve observation, shock wave lithotripsy, retrograde intrarenal surgery (RIRS; i.e. ureteroscopic approaches), percutaneous nephrolithotomy (PCNL), or a combination of these approaches. OBJECTIVES To assess the effects of percutaneous nephrolithotomy (PCNL) versus retrograde intrarenal surgery (RIRS) for the treatment of renal stones in adults. SEARCH METHODS We performed a comprehensive search of the Cochrane Library, MEDLINE, Embase, Scopus, and two trials registries up to 23 March 2023. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized controlled trials that evaluated PCNL (grouped by access size in French gauge [Fr] into three groups: ≥ 24 Fr [standard PCNL], 15-23 Fr [mini-PCNL and minimally invasive PCNL], and < 15 Fr [ultra-mini-, mini-micro-, super-mini-, and micro-PCNL]) versus RIRS. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data from the included studies. Our primary outcomes were stone-free rate, major complications, and need for secondary interventions. Our main secondary outcomes were unplanned medical visits to emergency/urgent care or outpatient clinic, length of hospital stay, ureteral stricture or injury, and quality of life. We performed statistical analyses using a random-effects model. We rated the certainty of evidence using GRADE criteria. We adopted a minimally contextualized approach with predefined thresholds for minimal clinically important differences (MCIDs). MAIN RESULTS We included 42 trials assessing the effects of PCNL versus RIRS in 4571 randomized participants. Twenty-two studies were published as full-text articles, and 20 were published as abstract proceedings. The average size of stones ranged from 10.1 mm to 39.1 mm. Most studies did not report sources of funding or conflicts of interest. The main results for the most important outcomes are summarized below. Stone-free rate PCNL compared with RIRS may improve stone-free rates (risk ratio [RR] 1.13, 95% confidence interval [CI] 1.08 to 1.18; I2 = 71%; 39 studies, 4088 participants; low-certainty evidence). Based on 770 participants per 1000 being stone-free with RIRS, this corresponds to 100 more (62 more to 139 more) stone-free participants per 1000 with PCNL (an absolute difference of 10%, where the predefined MCID was 5%). Major complications PCNL compared with RIRS probably has little or no effect on major complications (RR 0.86, 95% CI 0.59 to 1.25; I2 = 15%; 34 studies, 3649 participants; moderate-certainty evidence). Based on 31 complications in the RIRS group, this corresponds to six fewer (13 fewer to six more) major complications per 1000 with PCNL (an absolute difference of 0.6%, where the predefined MCID was 2%). Need for secondary interventions PCNL compared with RIRS may reduce the need for secondary interventions (RR 0.31, 95% CI 0.17 to 0.55; I2 = 61%; 21 studies, 2005 participants; low-certainty evidence). Based on 222 secondary interventions in the RIRS group, this corresponds to 153 fewer (185 fewer to 100 fewer) secondary interventions per 1000 with PCNL (an absolute difference of 15.3%, where the predefined MCID was 5%). Unplanned medical visits No studies reported unplanned medical visits. Length of hospital stay PCNL compared with RIRS may extend length of hospital stay (mean difference 1.04 days more, 95% CI 0.27 more to 1.81 more; I2 = 100%; 26 studies, 2804 participants; low-certainty evidence). This effect size is greater than the predefined MCID of one day. Ureteral stricture or injury PCNL compared with RIRS may have little or no effect on the occurrence of ureteral strictures (RR 0.93, 95% CI 0.39 to 2.21; I2 = 0%; 13 studies, 1574 participants; low-certainty evidence). Based on 14 ureteral strictures in the RIRS group, this corresponds to one fewer (nine fewer to 17 more) ureteral strictures per 1000 with PCNL (an absolute difference of 0.1%, where the predefined MCID was 2%). Quality of life No studies reported quality of life. AUTHORS' CONCLUSIONS Based on a large body of evidence from 42 trials, we found that PCNL compared with RIRS may improve stone-free rates and may reduce the need for secondary interventions, but probably has little or no effect on major complications. PCNL compared with RIRS may have little or no effect on ureteral stricture rates and may increase length of hospital stay. We found no evidence on unplanned medical visits or participant quality of life. Because of the considerable shortcomings of the included trials, the evidence for most outcomes was of low certainty. Access size for PCNL was less than 24 Fr in most studies that provided this information. We expect the findings of this review to be helpful for shared decision-making about management choices for individuals with renal stones.
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Affiliation(s)
- Leah Soderberg
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Onuralp Ergun
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maylynn Ding
- School of Medicine, McMaster University, Hamilton, Canada
| | - Robin Parker
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, Canada
| | - Michael S Borofsky
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vernon Pais
- Department of Surgery, Dartmouth Medical School, Lebanon, NH, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
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