The feasibility of endourological surgery in low-resource settings

A Global Survey to Assess Urologists' Attitudes Towards Suction Technology in Endourology by the European Association of Urology Section of Endourology and Progressive Endourological Association for Research and Leading Solutions

OBJECTIVE

To assess urologists' perceptions and current practices of using suction-based techniques and technologies in percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) for kidney stones.

MATERIALS AND METHODS

A customized web-based 28-item questionnaire was created. All participation was voluntary. The survey was hosted on Google Forms between November 15, 2023 and November 25, 2023. Descriptive statistics were applied to demographic details and categorical responses.

RESULTS

Six hundred thirty-two responses were received. 56.5% were from Asia. Around 41.6% of respondents underwent an endourology fellowship. Personal experience of suction for PCNL was noted in 55.4% and 42.7% for RIRS. Exactly 34.9% believe that currently there is enough evidence that suction can improve stone-free rates and lower complications for both endourology surgeries. Around 55.69% believe that as evidence evolves, suction has the potential to be a game changer in endourology management of urolithiasis. Exactly 55.7% believe that the leading barrier to the adoption of suction in endourology is the lack of availability of technology. Other barriers include lack of procedural standardization (37.65%), lack of evidence (34.9%), lack of proper training (29.58%) and lack of advocation in the current guidelines (17.72%).

CONCLUSION

Our survey shows that urologists are keen to adopt suction for PCNL and RIRS but the lack of definitive evidence, standardization, equipment availability and training preclude them from using so. More high-level evidence regarding the utility of suction in endourology is required for its routine adoption in clinical practice.

Stone disease in low-middle income countries. Could augmented reality have a role in its management?

Urolithiasis is a global phenomenon. Cystolithiasis is common in parts of Africa due to low protein intake and dehydration from endemic diarrhoeal illnesses. Nephrolithiasis is less prevalent than in high income countries, probably due to a variety of lifestyle issues, such as a more elemental diet, higher physical activity and less obesity. Although renal stones are less common in low-middle income countries (LMICs), the social and economic impacts of nephrolithiasis are still considerable; many stones present late or with complications such as upper urinary tract obstruction or urosepsis. These may lead to the development of chronic kidney disease, or end-stage renal failure in a small proportion of cases, conditions for which there is very poor provision in most LMICs. Early treatment of nephrolithiasis by the least invasive method possible can, however, reduce the functional consequences of urinary stone disease. Although ESWL is uncommon, and endoscopic interventions for stone are not widespread in most of Africa, percutaneous nephrolithomy and ureteroscopic renal surgery are viable techniques in those regional centres with infrastructure to support them. Longitudinal mentoring has been shown to be a key step in the adoption of these minimally invasive procedures by local surgeons, something that has been difficult during the COVID-19 pandemic due to travel restriction. Augmented reality (AR) technology is an alternative means of providing remote mentoring, something that has been trialled by Urolink, the MediTech Trust and other global non-governmental organisations during this period. Our preliminary experience suggests that this is a viable technique for promulgating skills in LMICs where appropriate connectivity exists to support remote communication. AR may also have long term promise for decreasing the reliance upon short-term surgical visits to consolidate competence, thereby reducing the carbon footprint of global surgical education.