Invasive management of proximal ureteral calculi during pregnancy

Double-J Ureteral Stenting in Obstetrics and Gynecology: Pivotal or Problematic?

Background and Objectives: Double-J stents are urinary catheters that are frequently used in urology. They are now also used in other specialist areas such as obstetrics and gynecology. However, the use of double-J stents is not without side effects. The aim of this review was to highlight the indications and possible adverse effects of the use of these stents in obstetrics and gynecology. Materials and Methods: We analyzed works published after 1995 in the PUBMED, SCOPUS, and Web of Science databases related to the use of double-J stents in obstetrics and gynecology, as well as reported adverse events. We carried out a narrative review of the available literature on this topic. Results: We identified 69 relevant publications that we included in the review. In obstetrics, indications include the treatment of gestational hydronephrosis, some urological conditions during pregnancy, such as obstructive urinary calculi, with or without superinfection, or intraoperative use for cesarean section or hysterectomy after cesarean section, to protect from, or to solve, ureteral lesions. In gynecology, they are used preoperatively or intraoperatively to protect the ureter during gynecological operations in the pelvic area or postoperatively to repair some ureteral injuries. They are also indicated for ureteral obstructions that occur after pelvic radiotherapy for gynecological neoplasms. Complications associated with the use of double-J stents include more frequent urinary tract infections, lower urinary tract symptoms, calcifications and misplacements. Conclusions: Double-J stents are widely used in obstetrics and gynecology and are characterized by good efficiency and safety, although some side effects may occur (lower urinary tract symptoms, hematuria, complications in birth outcomes), which do not limit their use. Summary of evidence: In this review, we analyzed the indications and complications of double-J ureteral stenting in obstetric and gynecologic patients. We found that the procedure is safe, both in the treatment of ureteral obstruction and in the resolution of postoperative complications. No serious complications of ureteral stenting have been noted that would constitute a contraindication to its use. Future prospective studies in large patient cohorts are necessary to validate our data.

Surgical management of obstructing ureteral stones during pregnancy: A systematic review of different techniques

INTRODUCTION

Renal colic is the most common non-obstetric cause of abdominal pain during pregnancy and is associated with a higher risk of complications in these women. When invasive treatment is required, options are temporary drainage with ureteral stent (JJ) or percutaneous nephrostomy (PCN), or immediate definitive treatment with ureteroscopy (URS). Our goal was to review the safety and efficacy of these procedures in treating urolithiasis during pregnancy.

METHODS

Adhering to the PRISMA checklist guidelines, we searched PubMed, Embase, and Scopus databases for articles on the efficacy and complications of the three procedures in pregnant women. The quality of evidence and risk of bias were evaluated using the Critical Appraisal Skills Programme and the Institute of Health Economics tools.

RESULTS

We included 45 articles, totaling 3424 interventions in pregnant women - 2188 URS, 719 JJ, and 517 PCN. URS was the most assessed procedure, with stone-free rates comparable to the non-pregnant patients. The most frequent complications were lower urinary symptoms and infections independently of the intervention. Obstetric complications for all interventions included 167 cases of preterm labor, resulting in 24 premature births. No statistically significant differences in post-operative complications were reported between the procedures in the few comparative studies.

CONCLUSIONS

Despite the absence of high-quality studies, current evidence suggests that URS, JJ, and PCN are all safe and effective during pregnancy. As most patients submitted to temporary drainage require a second procedure post-delivery, primary URS appears more efficient. Therefore, it is the preferred option unless there are indications for temporary drainage.

The Effect of High- and Low-power Holmium Laser Settings for Transurethral Lithotripsy in the Management of Adults with Ureteral Stone

Since there is insufficient evidence to determine the best treatment of transurethral laser lithotripsy (TLL) in ureteral stones, this study compared the effectiveness and safety of TLL using high-power (HP) (100 W) and low-power (LP) (20 W) laser settings. All patients with maximally sized ureteral stones who were planned for transurethral holmium laser lithotripsy were enrolled in this open study. One of the two laser setting groups-LP or HP-was allocated to each alternate patient. Using IBM SPSS Statistics 24, the treatment groups were compared for operating time, intraoperative and postoperative problems (up to 1 year), and rates of stone-free recovery. Welch tests were employed to compare continuous data, whereas Fisher's exact or Chi-square tests were used to assess categorical variables. At P < 0.05, statistical significance was established. A total of 207 individuals were included and preoperative data were comparable between the two groups. The HP group had a considerably greater ablation rate and a significantly shorter procedure duration (42.61 ± 11.74 min) than the LP group (78.56 ± 25.91 min) ( P = 0.025). The Overactive Bladder Symptom Score and International Prostate Symptom Score were considerably higher in the HP group than in the LP group. Treatment effectiveness was considerably impacted by the location of the ureteral stone, according to univariate and multivariate logistic regression models. A HP laser setting of up to 100 W greatly shortens the duration of the process for treating ureteral stones without raising the risk of problems.

Ureterorenoscopy for stone disease in pregnancy: a literature review and update

PURPOSE OF REVIEW

Management of stone disease in pregnancy poses a challenge for all healthcare professionals involved in their care. During pregnancy, there is an increase in the incidence of urolithiasis. Major technological and procedural advances have been seen in the last decade for endoscopic management of urolithiasis. The purpose of this review is to provide a comprehensive workup of available literature on use of ureteroscopy for stone treatment during pregnancy.

RECENT FINDINGS

We identified 268 articles on screening, of which 28 were included in the final review. Overall adverse event rates were low, with no severe complications reported in the included studies. On multivariate analysis, the only significant correlation was an inverse relationship between calculated caseload and adverse obstetric events. No further correlation could be found between caseload, operation technique and adverse event rates. Data quality was low among the included studies.

SUMMARY

While ureteroscopy is a relatively safe and effective option for active stone treatment during pregnancy, they should be performed in experienced endourology centres in conjunction with obstetric teams.

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

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

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

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

Management of urolithiasis in pregnancy: A systematic review and meta-analysis

PURPOSE

Management of nephrolithiasis is unique in pregnancy and requires multidisciplinary care. To identify the effectiveness or safety of temporary drainage or definitive treatment methods to manage urolithiasis in pregnancy.

METHODS

The search strategy aimed to find both published and unpublished studies was conducted in August 2021. Studies published in any language on any date were considered for inclusion.

RESULTS

Of a total of 3349 publications, 36 studies were included in our qualitative evaluation and 32 studies in the quantitative synthesis. The commonly reported method was stent insertion (n = 29 studies), pneumatic (n = 12), laser (n = 9) lithotripsy, and stone removal using any devices (basket, grasper, or forceps) (n = 11). In seven studies, the authors reported the outcomes of conservative management, and the results showed that the stone-free rate is 54%, and symptom relief occurred in 62% of women. Seven eligible studies reported that 79.9% of urolithiasis were expulsed through stent insertion, while this rate was 94.6% among percutaneous nephrostomy use in two included studies, 88.5% for pneumatic lithotripsy (n = 7 studies), and 76.4% for laser lithotripsy (n = 4 studies), or 95.4% for stone removal method. In addition, adverse events were reported in less than 10% of pregnant women.

CONCLUSIONS

The results showed that stent, pneumatic or laser lithotripsy, and ureteroscopic stone removal were the commonest used methods in the included studies. They can be effective and safe treatment approaches without major maternal or neonatal complications, and could be introduced as an effective and safe therapeutic method for urolithiasis during pregnancy. However, most of the included studies had moderate quality according to critical appraisal checklists. Further prospective studies are needed to reach a conclusion.

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.

A Systematic Review of Elective Laser Therapy during Pregnancy

Introduction: Currently, lasers are used to treat many diseases and their complications. However, the use of lasers in pregnant patients is still controversial. Methods: In this review, the application of lasers in the fields of urology, surgery, obstetrics, dermatology, and musculoskeletal disorders is evaluated. The following keywords were used to search through PubMed, Google Scholar, and Scopus: pregnancy, laser, urolithiasis, endovenous laser ablation (EVLA) or treatment, leg edema, varicose vein, venous insufficiencies, hair removal, pigmentation, telangiectasia, vascular lesions, Q switch laser, diode laser, holmium, holmium-YAG laser, erbium laser and Pulsed dye laser, low-level laser therapy, high-intensity laser therapy, pain, musculoskeletal disorders, twin to twin transfusion syndrome (TTTS), amnioreduction, and safety. Results: Totally, 147 articles were found, and their abstracts were evaluated; out of 53 articles extracted, 14 articles were about dermatology, 24 articles were about urology, 12 articles were about obstetrics and gynecology, 10 articles were about musculoskeletal disorders and three articles were related to surgery. Conclusion: Laser therapy can be used as a safe treatment for urolithiasis, skin diseases, TTTS and varicose veins of the lower extremities. However, the use of laser therapy for musculoskeletal disorders during pregnancy is not recommended due to lack of evidence, and also we cannot recommend endovenous ablation.

Management of ureteric stone in pregnancy: a review

Background

Urolithiasis in pregnancy is a major health concern and is one of the most common causes for non-obstetrical abdominal pain and subsequent hospital admission during pregnancy. The incidence of urinary calculi during pregnancy varies in the range of 1/200 to 1/2000. Acute ureteric colic in pregnancy is associated with significant potential risks to both mother and fetus. Significant anatomic and functional changes occur in pregnancy which not only lead to stone formation but also create diagnostic dilemma. The diagnosis of ureteric calculi can be incorrect in about 28% of pregnant patients.

Main body

Management of ureteric stone during pregnancy is remaining to be a challenge for the treating urologist. Because of the inability to use good imaging options for the diagnosis confirmation and more invasive approach for the treatment, management continues to be difficult. The main threats are preterm labor with delivery and premature rupture of membranes. Other pregnancy complications are obstructive uropathy, gestational diabetes mellitus, recurrent abortions and pre-eclampsia. Management of diagnosed ureteric stone is unique in the pregnant population and requires multi-disciplinary care. It should be individualized for each patient and moves preferably from conservative to invasive approaches sequentially. With continued advancements in endourological techniques, few definitive treatment options are also available for such patients.

Conclusion

There are several lacunae related with the diagnostic imaging, medical expulsive therapy, reliability of ureteral stent/percutaneous nephrostomy insertions and safety of ureteroscopy during pregnancy. Herein, we review the management of ureteric stone during pregnancy, the various diagnostic modalities and treatment options with their advantages and disadvantages. We also proposed our management algorithm to deal with such clinical scenario in this particular population.

Obstetric outcomes of pregnancy complicated by urolithiasis: a retrospective cohort study

OBJECTIVES

Evaluate the association between urolithiasis during pregnancy and obstetric outcomes outside the context of urological intervention.

METHODS

We conducted a retrospective cohort study of singleton, non-anomalous gestations delivered at 23-42 weeks in California from 2007 to 2011. Maternal outcomes (preterm delivery [early (<32 weeks) and late (<37 weeks)], preeclampsia, gestational diabetes, cesarean deliveries, urinary tract infection [UTI] at delivery, chorioamnionitis, endomyometritis, and maternal sepsis) and newborn outcomes (seizure, respiratory distress syndrome, hypoglycemia, jaundice, and neonatal abstinence syndrome [NAS]) were compared using χ2-tests and multivariable logistic regression.

RESULTS

A total of 2,013,767 pregnancies met inclusion criteria, of which 5,734 (0.28%) were complicated by urolithiasis. Stone disease during pregnancy was associated with 30% greater odds of each early (aOR 1.30; 95% CI 1.19-1.43) and late (aOR 1.29; 95% CI 1.18-1.41) preterm delivery. Cesarean delivery, UTI at delivery, gestational hypertension, gestational diabetes, preeclampsia, and sepsis were all significantly positively associated with urolithiasis. Odds of NAS (aOR 2.11; 95% CI 1.27-3.51) and jaundice were significantly greater in the neonates of stone-forming patients (aOR 1.08; 95% CI 1.01-1.16).

CONCLUSIONS

Urolithiasis during pregnancy was associated with 30% greater odds of preterm delivery and increased risk of myriad metabolic, hypertensive, and infectious disorders of gestation. Neonates born to stone-forming patients were more than twice as likely to develop neonatal abstinence syndrome but did not have significantly greater odds of complications of prematurity.