Global Trends in Incidence and Burden of Urolithiasis from 1990 to 2019: An Analysis of Global Burden of Disease Study Data

Prevention, diagnosis, and treatment of urolithiasis in geriatric patients - differences, similarities and caveats in comparison to the general population

PURPOSE OF REVIEW

Purpose of the review is to address management and prevention of urolithiasis in elderly patients examining the dynamic interplay between general measures, dietary adjustments, lifestyle modifications, and targeted pharmacological and/ or surgical interventions. The goal is to provide understanding of the evolving strategies required for effective urolithiasis prevention in the geriatric population.

RECENT FINDINGS

Age-specific diagnostic considerations are necessary because urolithiasis in the elderly population is characterized by bigger stones, greater peri-operative risks, and heightened symptom severity. When comorbidities are present, conservative treatments - especially analgesia - provide difficulties. Surgical procedures prove to be safe and effective, with complication rates and practical application comparable to younger cohorts. Prevention approaches that include lifestyle changes and the investigation of novel pharmaceutical options such as sodium-dependent glucose co-transporter 2 (SGLT-2)-inhibitors are promising in the management of urolithiasis in the elderly population.

SUMMARY

Our review offers a thorough investigation of urolithiasis in the elderly population, elucidating distinct clinical manifestations, complex diagnostic issues, and treatment implications. The safety and effectiveness of ureteroscopy in older patients, as well as the possible prophylactic function of SGLT-2-I, offer crucial insights for clinicians. Subsequent studies are necessary to enhance age-specific therapies, addressing the distinct obstacles presented by urolithiasis in the elderly population within this rapidly growing demographic.

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.

A new protocol for renal collecting system sterilization with antibiotic irrigation during lithotripsy in retrograde intrarenal surgery: a prospective, comparative study

PURPOSE

To present a new protocol using antibiotic irrigation during lithotripsy in retrograde intrarenal surgery (RIRS) to provide sterility of the renal collecting system.

METHODS

This prospective study included 102 patients who underwent RIRS between January 2022 and August 2023. The patients were examined in two groups as those who received antibiotic irrigation (n:51) and standard irrigation (n:51). In the antibiotic irrigation group, 80 mg of gentamicin was dissolved in normal saline in a 3 L irrigation pouch to obtain a 26.7 mg/L concentration. In the standard irrigation group, normal saline was used. Preoperative information, including age, sex, body mass index (BMI), ASA score, stone side, volume, and density, and the Seoul National University Renal Stone Complexity (S-ReSC) score. The groups were compared with respect to postoperative fever (> 38 °C), urinary tract infection (UTI), systemic inflammatory response syndrome (SIRS), infectious complications such as sepsis, and stone-free rate.

RESULTS

No statistically significant difference was determined between the groups with respect to age, sex, BMI, ASA score, stone side, volume and density, and S-ReSC score (p > 0.05 for all). Statistically significant differences were determined between the groups with respect to postoperative fever (p = 0.05), SIRS (p = 0.05), and hospital length of stay (p = 0.05). Sepsis was observed in one patient in the standard irrigation group and in none of the antibiotic irrigation group.

CONCLUSION

The reliability, efficacy, and utility of antibiotic irrigation during lithotripsy in RIRS were presented in this study as a new protocol for sterilization of the renal collecting system which will be able to reduce infectious complications.

Phagocytosis model of calcium oxalate monohydrate crystals generated using human induced pluripotent stem cell-derived macrophages

Macrophages play a role in nephrolithiasis, offering the possibility of developing macrophage-mediated preventive therapies. To establish a system for screening drugs that could prevent the formation of kidney stones, we aimed to develop a model using human induced pluripotent stem cell (iPSC)-derived macrophages to study phagocytosis of calcium oxalate monohydrate (COM) crystals. Human iPSCs (201B7) were cultured. CD14+ monocytes were recovered using a stepwise process that involved the use of growth factors and cytokines. These cells were then allowed to differentiate into M1 and M2 macrophages. The macrophages were co-cultured with COM crystals and used in the phagocytosis experiments. Live cell imaging and polarized light observation via super-resolution microscopy were used to visualize phagocytosis. Localization of phagocytosed COM crystals was observed using transmission electron microscopy. Intracellular fluorescence intensity was measured using imaging cytometry to quantify phagocytosis. Human iPSCs successfully differentiated into M1 and M2 macrophages. M1 macrophages adhered to the culture plate and moved COM crystals from the periphery to cell center over time, whereas M2 macrophages did not adhere to the culture plate and actively phagocytosed the surrounding COM crystals. Fluorescence assessment over a 24-h period showed that M2 macrophages exhibited higher intracellular fluorescence intensity (5.65-times higher than that of M1 macrophages at 4.5 h) and maintained this advantage for 18 h. This study revealed that human iPSC-derived macrophages have the ability to phagocytose COM crystals, presenting a new approach for studying urinary stone formation and highlighting the potential of iPSC-derived macrophages as a tool to screen nephrolithiasis-related drugs.

Urine cadmium and urolithiasis: A systematic review and meta-analysis

Exposure to cadmium may increase risk of urolithiasis, but the results remain inconclusive. This systematic review and meta-analysis aimed to access the association between cadmium exposure and urolithiasis. We searched Medline/PubMed, Embase, Web of Science Core Collection, and Cochrane Central for studies. The primary outcome was the incidence of urolithiasis compared to reference groups. We used relative risk as the summary effect measure. This meta-analysis included eight observational studies and divided into 39 study populations. Among 63,051 subjects, 5018 (7.96%) individuals had urolithiasis. The results indicated that people with an increment of 0.1 μg/g creatinine in urinary cadmium had a 2% increased risk of urolithiasis (pooled relative risk [RR], 1.02; 95% confidence interval [CI], 1.01-1.03) and there is no difference in the risk of urolithiasis in high and low cadmium exposure levels. Meanwhile, people with an increment of 0.1 μg/L in urinary cadmium had a 4% increased risk of urolithiasis (pooled RR, 1.04; 95% CI, 1.02-1.07). Our findings also showed similar associations in both sex, different region (Sweden, China, and Thailand), general and occupational population. The results indicate that cadmium exposure was significantly associated with an elevated risk of urolithiasis. Therefore, it is imperative to take steps to minimize cadmium exposure.

Identification of kidney stones in KUB X-ray images using VGG16 empowered with explainable artificial intelligence

A kidney stone is a solid formation that can lead to kidney failure, severe pain, and reduced quality of life from urinary system blockages. While medical experts can interpret kidney-ureter-bladder (KUB) X-ray images, specific images pose challenges for human detection, requiring significant analysis time. Consequently, developing a detection system becomes crucial for accurately classifying KUB X-ray images. This article applies a transfer learning (TL) model with a pre-trained VGG16 empowered with explainable artificial intelligence (XAI) to establish a system that takes KUB X-ray images and accurately categorizes them as kidney stones or normal cases. The findings demonstrate that the model achieves a testing accuracy of 97.41% in identifying kidney stones or normal KUB X-rays in the dataset used. VGG16 model delivers highly accurate predictions but lacks fairness and explainability in their decision-making process. This study incorporates the Layer-Wise Relevance Propagation (LRP) technique, an explainable artificial intelligence (XAI) technique, to enhance the transparency and effectiveness of the model to address this concern. The XAI technique, specifically LRP, increases the model's fairness and transparency, facilitating human comprehension of the predictions. Consequently, XAI can play an important role in assisting doctors with the accurate identification of kidney stones, thereby facilitating the execution of effective treatment strategies.

Alkaptonuria

Alkaptonuria is a rare inborn error of metabolism caused by the deficiency of homogentisate 1,2-dioxygenase activity. The consequent homogentisic acid (HGA) accumulation in body fluids and tissues leads to a multisystemic and highly debilitating disease whose main features are dark urine, ochronosis (HGA-derived pigment in collagen-rich connective tissues), and a painful and severe form of osteoarthropathy. Other clinical manifestations are extremely variable and include kidney and prostate stones, aortic stenosis, bone fractures, and tendon, ligament and/or muscle ruptures. As an autosomal recessive disorder, alkaptonuria affects men and women equally. Debilitating symptoms appear around the third decade of life, but a proper and timely diagnosis is often delayed due to their non-specific nature and a lack of knowledge among physicians. In later stages, patients' quality of life might be seriously compromised and further complicated by comorbidities. Thus, appropriate management of alkaptonuria requires a multidisciplinary approach, and periodic clinical evaluation is advised to monitor disease progression, complications and/or comorbidities, and to enable prompt intervention. Treatment options are patient-tailored and include a combination of medications, physical therapy and surgery. Current basic and clinical research focuses on improving patient management and developing innovative therapies and implementing precision medicine strategies.

The Management of Large Bladder Calculi by Utilizing Dual-Action Percutaneous Lithotripsy via Suprapubic Tube Sheath: A Novel Technique

Bladder calculi commonly develop in patients with poor bladder emptying or those with retained foreign bodies within the bladder, leading to irritative voiding symptoms, hematuria, and an increased likelihood of refractory urinary tract infections. While many techniques exist for the treatment of bladder calculi, including endoscopic and open-surgical approaches, our novel technique may help manage exceptionally large or difficult-to-treat bladder calculi effectively. We present three patients with symptomatic bladder calculi ranging from 1.3 cm to 6.8 cm in size who were successfully treated by using our novel technique. Percutaneous access to the bladder was obtained by using a suprapubic catheter trocar and sheath to enable the utilization of a dual-action lithotriptor. Sheath insertion and lithotripsy were performed under direct visualization with a rigid cystoscope via the native urethra. This technique is easily learned and can be safely employed in patients in whom other methods may pose risks of higher morbidity.

Does preoperative silodosin administration facilitate ureteral dilatation during flexible ureterorenoscopy? A randomized clinical trial

PURPOSE

To assess whether preoperative administration of silodosin can facilitate the placement of ureteral access sheath (UAS) prior to flexible ureteroscopy (F-URS) and reduce the occurrence of ureteric injury in challenging cases.

METHODS

This prospective randomized clinical trial was carried out on 147 patients diagnosed with upper ureteric stone or stone kidney, non-stented. The patients were randomly divided into two equal groups. Group A (silodosin group) included patients in whom F-URS was done with daily preoperative intake of 8 mg silodosin for 1 week and group B (placebo/control group) included patients in whom F-URS was done with daily preoperative intake of placebo tablets.

RESULTS

In group A, a total of 23 (33.3%) experienced ureteral wall injury following UAS insertion, while in group B, this occurred in 40 patients (59.7%). There was a statistically significant difference in the grade of ureteral wall injury between the two groups (P < 0.001). In the multiple regression analysis, age, operative time and silodosin were found to be significant risk factors for ureteral wall injury (P = 0.007, 0.041 and < 0.001, respectively).

CONCLUSIONS

The administration of silodosin prior to retrograde intrarenal surgery (RIRS) effectively prevented significant ureteral wall damage and reduced initial postoperative discomfort.

StoneMod 2.0: Database and prediction of kidney stone modulatory proteins

Stone modulators are various kinds of molecules that play crucial roles in promoting/inhibiting kidney stone formation. Several recent studies have extensively characterized the stone modulatory proteins with the ultimate goal of preventing kidney stone formation. Herein, we introduce the StoneMod 2.0 database (https://www.stonemod.org), which has been dramatically improved from the previous version by expanding the number of the modulatory proteins in the list (from 32 in the initial version to 17,130 in this updated version). The stone modulatory proteins were recruited from solid experimental evidence (via PubMed) and/or predicted evidence (via UniProtKB, QuickGO, ProRule, STITCH and OxaBIND to retrieve calcium-binding and oxalate-binding proteins). Additionally, StoneMod 2.0 has implemented a scoring system that can be used to determine the likelihood and to classify the potential stone modulatory proteins as either "solid" (modulator score ≥ 50) or "weak" (modulator score < 50) modulators. Furthermore, the updated version has been designed with more user-friendly interfaces and advanced visualization tools. In addition to the monthly scheduled update, the users can directly submit their experimental evidence online anytime. Therefore, StoneMod 2.0 is a powerful database with prediction scores that will be very useful for many future studies on the stone modulatory proteins.

A comparative study of intranasal desmopressin and intranasal ketamine for pain management in renal colic patients: a randomized double-blind clinical trial

OBJECTIVE

Urolithiasis is one of the most common urological diseases worldwide, usually presenting as renal colic that leads to severe pain that requires analgesic treatment. This study aimed to compare the efficacy of ketamine and desmopressin in the pain management of renal colic patients.

METHODS

This double-blind, randomized clinical trial was conducted on renal colic patients referred to the emergency department from June 2021 to July 2022. Patients were randomly assigned to three groups. In the desmopressin group, patients were treated with intranasal desmopressin and intravenous ketorolac. The ketamine group was treated with intranasal ketamine and ketorolac. The control group received ketorolac and an intranasal placebo. Vital signs were evaluated at baseline and 60 minutes; and pain scores were assessed at baseline, 10, 30, and 60 minutes after treatment.

RESULTS

Enrollment included 135 patients, the mean (standard deviation) age was 44.1±11.4 years, and 82 (60.7%) were men. The mean visual analog scale scores were significantly lower at 10, 30, and 60 minutes in the ketamine group (5.6±1.2, 3.0±1.1, and 0.9±0.9, respectively) compared to the control (8.2±1.1, 5.1±2.0, and 2.3±2.6, respectively) and desmopressin (6.7±1.8, 4.2±2.2, and 1.3±1.4, respectively) groups (P<0.05). Although patients in the desmopressin group had lower mean pain scores than the control group at 10, 30, and 60 minutes, this difference was only significant at 10 minutes after the intervention (P<0.05). No significant differences in vital signs were found at 60 minutes after treatment.

CONCLUSION

Ketamine showed more favorable analgesic effects in renal colic patients than desmopressin, although desmopressin showed efficacy in the first minutes posttreatment.

A retrospective cohort study, analyzing trends in management of upper urinary tract stones in the adult Israeli population

OBJECTIVE

To assess trends of surgical intervention in adults with upper urinary tract stones in Israel.

METHODS

A retrospective cohort study utilizing administrative databases held at Clalit Health Services, to identify all adults (⩾18 years) who underwent their first surgical treatment for upper tract urolithiasis. Descriptive statistics were employed to summarize baseline patient demographics and surgical trends were analyzed using the Cochrane-Armitage test for trend.

RESULTS

Between 2003 and 2020, 36,624 adult patients were treated surgically for upper tract urinary stones. Mean age was 53.6 years (SD16.1). During the period investigated, the number of insured by Clalit Health Services increased by 25% and the total number of surgically treated stones increased by 98.7%. By type of procedure: Ureteroscopy (URS) increased by 351%, percutaneous nephrolithotripsy (PCNL) increased by 67%, shockwave lithotripsy (SWL) declined by 79%. The number of procedures per 100,000 population grew from to 37.5 in 2003 to 58.05 in 2022. The percentage increase in total number of surgical procedures was 103% and 90% in males and females, respectively.

CONCLUSIONS

Our findings reveal significant increases in the total number of surgically treated stones over the investigated period. Notably, this increase far outpaced the growth in the number of individuals insured by Clalit Health Services. Further research and interventions are warranted to explore the underlying factors driving these trends and to develop targeted approaches for prevention, early detection, and minimally invasive treatment of upper urinary tract stones in Israel.

Exploring the relationship of supernumerary recurrent renal calculi formation and tick-borne infections: a case report

A 51-year-old male with a history of Cacchi-Ricci disease and long-standing infection with various species of Borrelia, Babesia, and Bartonella presented with recurrent symptoms of right-sided flank pain. Numerous renal calculi were identified on imaging. The etiology of the calculi had not been previously elucidated. Symptoms intermittently date back to 2002 when uric acid stones were identified. Subsequent calculi analysis revealed calcium oxalate stones. Despite the commonality of nephrolithiasis in patients with Cacchi-Ricci disease, the extreme number of calculi and recurrent presentation of symptoms persisted despite a plethora of medical evaluations, dietary changes, and hereditary testing. This case raises questions of etiology including possible immune deficiency and whether his uncommon microbial history contributes to recurrent stone formation.

Advancements in stone classification: unveiling the beauty of urolithiasis

PURPOSE

Urolithiasis has become increasingly prevalent, leading to higher disability-adjusted life years and deaths. Various stone classification systems have been developed to enhance the understanding of lithogenesis, aid urologists in treatment decisions, and predict recurrence risk. The aim of this manuscript is to provide an overview of different stone classification criteria.

METHODS

Two authors conducted a review of literature on studies relating to the classification of urolithiasis. A narrative synthesis for analysis of the studies was used.

RESULTS

Stones can be categorized based on anatomical position, size, medical imaging features, risk of recurrence, etiology, composition, and morphoconstitutional analysis. The first three mentioned offer a straightforward approach to stone classification, directly influencing treatment recommendations. With the routine use of CT imaging before treatment, precise details like anatomical location, stone dimensions, and Hounsfield Units can be easily determined, aiding treatment planning. In contrast, classifying stones based on risk of recurrence and etiology is more complex due to dependencies on multiple variables, including stone composition and morphology. A classification system based on morphoconstitutional analysis, which combines morphological stone appearance and chemical composition, has demonstrated its value. It allows for the rapid identification of crystalline phase principles, the detection of crystalline conversion processes, the determination of etiopathogenesis, the recognition of lithogenic processes, the assessment of crystal formation speed, related recurrence rates, and guidance for selecting appropriate treatment modalities.

CONCLUSIONS

Recognizing that no single classification system can comprehensively cover all aspects, the integration of all classification approaches is essential for tailoring urolithiasis patient-specific management.

Antibacterial properties and urease suppression ability of Lactobacillus inhibit the development of infectious urinary stones caused by Proteus mirabilis

Infectious urolithiasis is a type of urolithiasis, that is caused by infections of the urinary tract by bacteria producing urease such as Proteus mirabilis. Lactobacillus spp. have an antagonistic effect against many pathogens by secreting molecules, including organic acids. The aim of the study was to determine the impact of Lactobacillus strains isolated from human urine on crystallization of urine components caused by P. mirabilis by measuring bacterial viability (CFU/mL), pH, ammonia release, concentration of crystallized salts and by observing crystals by phase contrast microscopy. Moreover, the effect of lactic acid on the activity of urease was examined by the kinetic method and in silico study. In the presence of selected Lactobacillus strains, the crystallization process was inhibited. The results indicate that one of the mechanisms of this action was the antibacterial effect of Lactobacillus, especially in the presence of L. gasseri, where ten times less P. mirabilis bacteria was observed, compared to the control. It was also demonstrated that lactic acid inhibited urease activity by a competitive mechanism and had a higher binding affinity to the enzyme than urea. These results demonstrate that Lactobacillus and lactic acid have a great impact on the urinary stones development, which in the future may help to support the treatment of this health problem.

Tight junction and kidney stone disease

Defects of tight junction (TJ) are involved in many diseases related to epithelial cell functions, including kidney stone disease (KSD), which is a common disease affecting humans for over a thousand years. This review provides brief overviews of KSD and TJ, and summarizes the knowledge on crystal-induced defects of TJ in renal tubular epithelial cells (RTECs) in KSD. Calcium oxalate (CaOx) crystals, particularly COM, disrupt TJ via p38 MAPK and ROS/Akt/p38 MAPK signaling pathways, filamentous actin (F-actin) reorganization and α-tubulin relocalization. Stabilizing p38 MAPK signaling, reactive oxygen species (ROS) production, F-actin and α-tubulin by using SB239063, N-acetyl-L-cysteine (NAC), phalloidin and docetaxel, respectively, successfully prevent the COM-induced TJ disruption and malfunction. Additionally, genetic disorders of renal TJ, including mutations and single nucleotide polymorphisms (SNPs) of CLDN2, CLDN10b, CLDN14, CLDN16 and CLDN19, also affect KSD. Finally, the role of TJ as a potential target for KSD therapeutics and prevention is also discussed.

Prevalence of urolithiasis in China: a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled prevalence, as well as the spatial and temporal distribution, of urolithiasis among subjects in China.

MATERIALS AND METHODS

We conducted a comprehensive search of both Chinese and English databases to retrieve literature pertaining to the prevalence of urolithiasis in the indigenous Chinese population. A random-effects meta-analysis model was employed to calculate the pooled prevalence of urolithiasis. Subgroup analyses were conducted based on factors such as time, region, gender, and sample size. Prevalence and spatial distribution maps were created based on provinces and latitude/longitude coordinates.

RESULTS

A total of 46 studies conducted in 22 provinces across China were included in this meta-analysis and the pooled prevalence of urolithiasis, kidney stones, ureteric calculi, urethral and bladder stones were 8.1% (95% confidence interval [CI] 5.6-11.1%), 7.8% (95% CI 5.8-10.0%), 3.2% (95% CI 0.6-5.7%), 0.5% (95% CI 0.1-0.9%). Most of the urolithiasis prevalence screening in China was concentrated between 100° E and 120° E, with higher rates observed in low latitude areas. Subgroup analysis of kidney stones revealed that Guangdong (12.7%) and Guangxi (10.3%) had the highest prevalence, with the eastern developed area exhibiting higher rates compared to the west. The prevalence in males was higher than in females (odds ratio 1.67, 95% CI 1.46-1.92), although the gender gap has significantly reduced since 2006. Moreover, a greater sample size is associated with a decreased prevalence of urolithiasis.

CONCLUSIONS

The prevalence of urolithiasis is increasing in China, and there are noteworthy regional or provincial disparities in occurrence. It is worth noting that the current number of screening studies in some areas is insufficient. Additional investigations with appropriate sample sizes should be supplemented in time.

Evaluation of Inflammatory Parameters Following Extracorporeal Shock Wave Lithotripsy (ESWL) and Ureteroscopy for the Treatment of Proximal Ureteral Stones

Introduction Inflammation can arise as a consequence of both extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy (URS) treatments. Alterations in inflammatory parameters may serve as indicators of kidney injuries and the ensuing inflammation. This study aims to investigate the effects of ESWL and URS procedures on inflammatory parameters for proximal ureteral stone treatment. Materials and methods A prospective interventional study comprised 120 patients with confirmed stones measuring less than 10 mm in the upper half of the proximal ureter. These patients were randomly assigned to either the ESWL or URS treatment groups. Laboratory analyses encompassed interleukin-6 (IL-6), leukocyte count, fibrinogen levels, and erythrocyte sedimentation rate (ESR), which were assessed prior to the intervention, on the first postoperative day, and six months later. IL-6 levels in the serum were determined using a chemiluminescence immunoassay (CLIA). Results There was no significant difference in IL-6 levels between pre-intervention and the first post-intervention day in patients treated with ESWL (1.8 (1.4-2.59) pg/mL vs. 2.33 (1.22-3.19) pg/mL). However, for patients treated with URS, the pre-intervention IL-6 value was 2.9 (1.9-3.34) pg/mL, and it increased significantly to 7.1 (3.85-28.07) pg/mL on the first post-intervention day (p<0.001). On the first post-intervention day, levels of IL-6, CRP, leukocyte count, and ESR were significantly higher in patients treated with URS compared to ESWL (p<0.001; p<0.001; p=0.03; p=0.03, respectively). Conclusion Our research findings suggest that monitoring IL-6 levels can offer valuable insights into the degree of inflammation and tissue damage during and following observed procedures, particularly among patients undergoing URS, even within the initial days post-procedure.

Burden of female infertility in China from 1990 to 2019: a temporal trend analysis and forecasting, and comparison with the global level

BACKGROUND

Infertility is a common reproductive disease that affects not only individuals and families, but also the growth of the social population. Hence, understanding the burden of female infertility in China and worldwide is of great significance for the development of infertility prevention and treatment strategies.

METHODS

The Global Burden of Disease Study (GBD 2019) Data Resources were used to collect and collate relevant data on female infertility in China and worldwide from 1990 to 2019. The difference in the number, age-standardised prevalence rate (ASPR), disability-adjusted life years and age-standardised disability-adjusted life years rate (ASDR) of women with infertility in different periods and geographical areas were analysed. The autoregressive integrated moving average method was used to predict the ASPR and ASDR of female infertility in China and worldwide in the next 11years.

RESULTS

In the past 30years, the number of female infertility cases increased by 7.06million in China and 56.71million worldwide. The corresponding average annual increase of ASPR was 10.10% and 7.28%, respectively, and that of ASDR was 0.08% and 0.79%, respectively. In addition, there are differences in age and time between Chinese and global female infertility. In 1990, the crude prevalence rate of female infertility was the highest in women aged 40-44years and 35-39years in China and worldwide, respectively. In 2019, the crude prevalence rate of female infertility was still the highest in women aged 40-44years in China, whereas that around the world reached the highest in women aged 30-34years, which was significantly earlier. The forecast for the next 11years suggests that the ASPR and ASDR for female infertility in China will first rise and then decline, but the overall magnitude of change is not very significant, whereas the ASPR and ASDR for female infertility globally are still on the rise. The ASPR value of female infertility is expected to be 5025.56 in 100 000 persons in China and 3725.51 in 100 000 persons worldwide by 2030. The ASDR value of female infertility is expected to be 26.16 in 100 000 persons in China and 19.96 in 100 000 persons worldwide by 2030.

CONCLUSION

The burden of female infertility is still increasing in China and worldwide. Therefore, it is of great significance to pay more attention to infertile women, and advocate a healthy lifestyle to reduce the burden of disease for infertile women.

A new position utilizing the effect of gravity in proximal ureteral stones, ureteroscopic lithotripsy in the reverse Trendelenburg position: a prospective, randomized, comparative study

PURPOSE

To evaluate the effect of the reverse Trendelenburg position in patients undergoing ureteroscopic lithotripsy for proximal ureteral stones.

METHODS

The study included 167 patients who underwent ureteroscopic lithotripsy for proximal ureter stones between December 2020 and September 2022. The patients were randomly assigned to one of three groups: standard lithotomy (n:55), 10° reverse Trendelenburg (n:55), and 20° reverse Trendelenburg (n:57). Preoperative information, including age, sex, body mass index (BMI), previous shock wave lithotripsy (SWL), stone side, volume, and density, distance to the ureteropelvic junction (UPJ) of the stone, and hydronephrosis degree. Stone-free status was evaluated with computed tomography (CT) at 4 weeks postoperatively. The groups were compared in respect of stone migration, stone-free rate, use of flexible ureterorenoscope, operating time, postoperative length of stay in the hospital, and complications.

RESULTS

No statistically significant difference was determined between the groups with respect to age, sex, BMI, previous SWL, stone side, volume and density, distance to the UPJ of the stone, and hydronephrosis degree (p > 0.05 for all). Statistically significant differences were determined between the groups with respect to stone migration (p = 0.001), stone-free rate (p < 0.001), use of flexible ureterorenoscope (p = 0.01), operating time (p < 0.001), hospital length of stay (p < 0.001), postoperative fever (p = 0.002), and total complications (p = 0.01).

CONCLUSION

A new patient position is presented in this study, which can be used in ureteroscopic lithotripsy performed for proximal ureteral stones. The reverse Trendelenburg position constitutes a surgical method that can be used safely and successfully in the treatment of proximal ureteral stones.

TRIAL REGISTRATION NUMBER

NCT04894058, 05/21/2021, Prospectively registered.

Development of a new scoring system predicting medical expulsive therapy success on 4-10 mm distal ureteral stones: medical expulsive therapy stone score (METSS)

Ureteral stone passage by using medical expulsive therapy (MET) are affected by numerous radiological and clinical parameters. We aimed to construct a scoring system, which would be based on clinical and computed tomography (CT)-derived data, to predict the success of the MET approach. 186 patients presenting to urology clinic or emergency department with unilateral single 4-10 mm distal ureteral stone and who had MET were included. All patients were divided into two groups as the MET-successful group and the MET-unsuccessful group. The success rate of MET was 67.2%. Stone size ≥ 6.5 mm, stone density > 1078 HU, ureteral wall thickness (UWT) > 2.31 mm, ureteral diameter (UD) > 9.24 mm, presence of periureteral stranding (PUS) and presence of diabetes mellitus (DM) were stated as the independent risk factors. Based on the regression coefficients on multivariate logistic regression analysis, 1 point for stone size > 6.5 mm, 2 points for stone density > 1078 HU, 2 points for UWT > 2.31 mm, 3 points for UD > 9.24 mm, 1 point for presence of PUS and 1 point for presence of DM were assigned to patients for each risk factor. Higher medical expulsive therapy stone score (METSS) indicated lower MET success. All patients were classified into three risk groups according to METSS: low risk (0-3 points; success percentage: 92.8%); intermediate risk (4-5 points; success percentage: 60.4%) and high risk (6-10 points; success percentage: 8.3%). The METSS seems to separate successfully the patients with a favorable or adverse constellation of factors.

Does gender influence retrograde intrarenal surgery (RIRS) outcomes? Data from the Flexible Ureteroscopy Outcomes Registry (FLEXOR)

INTRODUCTION AND OBJECTIVES

As well established flexible ureteroscopy (RIRS). There is still no evidence if gender can have any influence on the outcomes and complication when performing. This study aims to evaluate the role that gender has in performing flexible ureteroscopy from a large series of patients.

METHODS

This study retrospectively analyzed patients who underwent RIRS for renal stones from January 2018 to August 2021 within the multicentric FLEXOR registry. Demographics, stone characteristics, perioperative findings, results and complications were analyzed and compared between gender groups.

RESULTS

A total of 6669 patients were included, 66.1% were male and 33.9% were female. Stone characteristics was comparable between groups. Female patients had significant higher fever and positive urine culture rates (12% vs. 8% and 37% vs. 34%). Also, females had a slight longer hospital stay (3.8 vs. 3.5 days; P < 0.001) and more residual fragments after the procedure (23.03% vs. 20.97 (P = 0.032). Overall complications were slightly significantly higher in women (15.74% vs. 14% (P = 0.042)) mainly at the expense of fever rates (6.9% vs. 5.7%) whereas the risk of sepsis was similar in both groups. A multivariate analysis showed that larger stone size, multiple and lower pole stones seem to have a negative impact in the incidence of residual stones and complications.

CONCLUSION

Our real life global study reflects that female gender may have a correlation with a slightly increased residual fragment rate and overall low grade complications. However, women can safely be treated with RIRS with no increased the rate of sepsis with appropriate care.

Comparative Effectiveness Randomized Clinical Trial Using Next-generation Microbial Sequencing to Direct Prophylactic Antibiotic Choice Before Urologic Stone Lithotripsy Using an Interprofessional Model

Background

Next-generation sequencing (NGS) methods for microbial profiling have increased sensitivity to detect urinary pathogens.

Objective

To determine whether NGS microbial profiling can be used to guide antibiotic prophylaxis and reduce infection compared with the standard of care.

Design setting and participants

A prospective randomized controlled clinical trial of patients undergoing urologic stone interventions at an academic health center from December 2019 to January 2022 was conducted. Urine was collected at the preoperative visit for standard culture and intervention NGS diagnostics. Evaluable patients were culture negative, met 2-wk follow-up, and did not cancel surgery. Of 240 individuals (control = 121, intervention = 119), 83 control and 74 intervention patients were evaluable.

Intervention

Microbial findings (paired quantitative polymerase chain reaction and NGS) were sent to an infectious disease pharmacist to recommend prophylactic antimicrobial regimen.

Outcome measurements and statistical analysis

The primary outcome was postoperative urinary infection within the follow-up period (Fisher's exact test). The primary outcome was analyzed by modified intent-to-treat (mITT) and per-protocol analyses. Secondary endpoints considered included positive culture concordance, antibiotic use, and adverse events. Additional post hoc analyses investigated factors contributing to infection (univariate logistic regression).

Results and limitations

The intervention significantly reduced postsurgical urinary infection risk by 7.1% (-0.73%, 15%) compared with the standard of care in the mITT analysis (1.4% vs 8.4%, p = 0.045) or by 8.5% (0.88%, 16%) compared with the per-protocol analysis (0% vs 8.5%, p = 0.032). NGS-guided treatment altered the distribution of antibiotics used (p = 0.025), and antibiotics poorly matched with NGS findings were associated with increased infection odds (odds ratio [OR] = 5.9, p = 0.046). Women were at greater odds to develop infection (OR = 10, p = 0.03) and possessed differentiated microbial profiles (p < 0.001).

Conclusions

Urinary microbial NGS-guided antibiotic prophylaxis before endoscopic urologic stone lithotripsy improves antibiotic selection to reduce healthcare-associated urinary infections; however, treatment efficacy may be limited by the ability to adhere to the recommended protocol.

Patient summary

We investigated whether microbial DNA sequencing could improve the selection of antibiotics before kidney stone surgery in patients not known to have any bacteria in the urine on standard culture. We found that using microbe DNA to guide antibiotic choices decreased postoperative infection rate and may encourage individualized use of available antibiotics.

Longitudinal trend of urolithiasis incidence rates among world countries during past decades

INTRODUCTION

This study explores the trend of urolithiasis in various countries and categorizes the countries in terms of how their urolithiasis incidence rate has changed over time.

METHODS

The incidence rate of urolithiasis in 204 countries from 1990 to 2019, extracted from the Global Burden of Disease study, has been analyzed.

RESULTS

According to the results, all regions had experienced an increasing trend in urolithiasis rate, except for Eastern Europe, Central Europe, and Southeast Asia regions (decreasing rates of -71.4, -56.2, and -9.2 per 100000, respectively). Moreover, the Caribbean region had the highest increasing trend of urolithiasis rates, and Central Asia was in the next rank (increasing rate of 48.3 and 34.3 per 100,000, respectively, p-value < .05). Also, African regions revealed significant increasing trends over time (p-value < 0.05). The outstanding findings in cluster analysis showed that Afghanistan, Andorra, and Comoros had the most decreasing trend in urolithiasis rates over time (decreasing rate of -128.2 per 100000, p-value < .001). Cuba, Cyprus, Czechia, the Democratic People's Republic of Korea, Denmark, and Djibouti were in the next rank in terms of decreasing rate (decreasing rate of -92.3 per 100000, p-value < .001). In addition, urolithiasis rates in Congo, Eswatini, Gabon, and Grenada have the most increasing trend (increasing rate of 116.1 per 100000, p-value < .001).

CONCLUSION

The trend of urolithiasis rates was significantly increased in most countries, and Congo, Eswatini, Gabon, and Grenada had the highest trend among others. Also, Afghanistan, Andorra, and Comoros revealed the most decreasing rates, and the trend has dropped remarkably in several other countries.

Chinese mini percutaneous nephrolithotomy for upper urinary calculi under local infiltration anesthesia

Percutaneous nephrolithotomy is generally performed under general or regional anesthesia; however, it is rarely performed under local infiltration anesthesia (LIA). This study aimed to assess the safety and effectiveness of Chinese mini percutaneous nephrolithotomy (MPCNL) for upper urinary calculi under LIA. A retrospective analysis of 52 patients with upper urinary stones who underwent MPCNL under LIA from April 2019 to May 2022 was performed. Pethidine and Phenergan were intramuscularly injected 30 minutes preoperatively. Oxybuprocaine hydrochloride gel was applied to the urethra for lubricating and mucosal anesthesia. Ropivacaine hydrochloride and lidocaine were injected into the whole percutaneous channel for local anesthesia. An 8/9.8F ureteroscope and an 18F vacuum-assisted access sheath were applied in MPCNL. All 52 patients tolerated procedures and underwent operations successfully; none of them converted the anesthesia method or required additional analgesia. The mean visual analogue scale scores intraoperatively and at 6 hours, 24 hours, and 48 hours after surgery were 3.25 ± 0.52, 3.13 ± 0.69, 2.25 ± 0.56, and 1.58 ± 0.50, respectively. The stone free rate was 84.6%. Complications were seen in 6 (11.5%) patients, including fever in 2 patients (Clavien I), renal colic in 1 patient (Clavien I), clinically insignificant bleeding in 2 patients (Clavien I), and urinary tract infection in 1 patient (Clavien II). No severe complications were observed in any patients. Chinese MPCNL under LIA was a feasible option and achieved good outcomes in appropriately selected patients, and it may become the routine procedure for general patients.

Serum and 24-hour urinary tests cost-effectiveness in stone formers

OBJECTIVE

To assess the routine serum and 24-hour urine tests proficiency in diagnosing the baseline metabolic abnormality of kidney stone formers.

METHODS

This study analyzes the routine serum and 24-hour urine tests proficiency in diagnosing the baseline metabolic abnormality of kidney stone formers. The sensitivity and specificity, false positive, and negative results of the tests are extracted from diagnostic kits used in the laboratories of the target community. To accurately infer the results, a simulation based on 1000 people was used through 22 standard laboratory tests (Additional File 2), including calcium, oxalate, phosphate, uric acid, sulfate, potassium, sodium, citrate, and magnesium in 24-hour urine; and calcium, creatinine, Vit D, uric acid, and intact parathyroid hormone (PTH) in serum. The incremental cost-effectiveness ratio (ICER) was calculated and compared for each diagnostic test versus other diagnostic tests according to the incremental cost required for correct diagnoses of stone causes.

RESULTS

Urinary uric acid, citrate, and serum potassium constitute the cost-effectiveness boundary curve in this study. This means that other diagnostic tests are not cost-effective compared to these three tests in terms of indexing at least one item of cost and effectiveness. The ICER index for each correct diagnosis with the urinary uric acid test was $ 1.25 per diagnosis, the most cost-effective test compared to serum potassium and urinary citrate.

CONCLUSION

The simplified blood and 24-hour urine metabolic evaluation, including urinary uric acid, citrate, and serum potassium, constitute the cost-effectiveness boundary curve. The most cost-effective test was urinary uric acid measurement.

Comparative Analysis of Surgical Outcomes of Flexible Ureteroscopy and Da Vinci Robotic Surgery in Community Patients with Renal Pelvic Stones Larger than 2 cm

Background and Objectives: This study evaluated and compared the surgical outcomes of retrograde intrarenal surgery (RIRS) lithotripsy versus robot-assisted laparoscopic pyelolithotomy (RAPL) in community patients with renal pelvic stones larger than 2 cm. Materials and Methods: A total of 77 patients who underwent RIRS (RIRS group, n = 50) or RAPL (RAPL group, n = 27) at our institution between December 2016 and July 2022 were recruited. A single surgeon performed all surgical operations. Preoperative, operative, and postoperative data were recorded. The study evaluated various clinical outcomes, namely, urinary tract infections, analgesic use, emergency room readmissions, stone clearance rates, surgical complications, and medical expenditures associated with the treatment courses, and compared them between the groups. Results: The RAPL group had a larger mean stone diameter and higher degree of hydronephrosis than the RIRS group did. The RIRS group had superior outcomes regarding operative time, length of postoperative hospital stay, surgical wound pain, and medical expenditures. Regarding postoperative outcomes, comparable rates of postoperative urinary tract infection, prolonged analgesic use, and emergency room readmissions were observed between the groups. However, the RAPL group had a higher stone clearance rate than the RIRS group did (81.5% vs. 52.0%, p = 0.014). Conclusions: For the surgical treatment of renal pelvis stones larger than 2 cm, RAPL has a superior stone clearance rate than RIRS; however, RIRS achieves superior outcomes in terms of medical expenditures, length of hospital stay, and surgical wound pain. Both procedures were equally safe.

Efficacy and safety of various endosurgical procedures for management of large renal stone: a systemic review and network meta-analysis of randomised control trials

Urolithiasis is the most common benign urological health condition. It has contributed sizeable burden of morbidity, disability, and medical health expenditure worldwide. There is limited high level of evidence on the efficacy and safety of treatment options of large renal stones. This network meta-analysis has examined the effectiveness and safety of various large renal stone management strategies. Systematic review and network meta-analysis (NMA) study design was employed to summarize comparative randomized controlled trials on humans with a diagnosis of renal stone larger than or equal to 2 cm in size. Our searching strategy was based on the Population, Interventions, Comparison, Outcomes, and Study (PICOS) approach. Medline via PubMed, Embase, Google scholar, SCOPUS, Science Direct, Cochrane library, Web of Science, and ClinicalTrials.gov were searched from inception to March 2023 to find eligible articles. Data extraction, screening, selection and risk of bias assessment were conducted by two independent reviewers. We found ten randomised control trials which consists 2917 patients, nine of them were labeled as low risk and one article was high risk. This network meta-analysis found that SFR was 86% (95% CI 84-88%) for Mini-PCNL, 86% (95% CI 84-88%) for standard PCNL, 79% (95% CI:73-86%) for RIRS, and 67% (95%CI:49-81 for staged URS for management of large renal stone. Overall complication rate was 32% (95% CI 27-38%) for standard PCNL, 16% (95% CI 12-21%) for Mini-PCNL, and 11% (95% CI 7-16%) for RIRS. Mini-PCNL (RR = 1.14 (95% CI 1.01-1.27) and PCNL (RR = 1.13 (95% CI 1.01-1.27)) were statistically associated with a higher SFR compared to RIRS. The pooled mean hospital stays were 1.56 days (95% CI 0.93-2.19) for RIRS, 2.96 days (95% CI 1.78-4.14) for Mini-PCNL, 3.9 days (95% CI 2.9-4.83) for standard PCNL, and 3.66 (95% CI 1.13-6.2) for staged URS. Mini-PCNL and standard PCNL were the most effective treatment options with significant morbidity and length of hospital stay, while RIRS was the safest management option with acceptable SFR, low morbidity, and short hospital stay.

Prevalence of Stone Disease and Procedure Trends in the United States

OBJECTIVE

To evaluate the prevalence of stone disease and procedure trends among US commercial and Medicare populations.

METHODS

Retrospective analyses for a US commercial population and Medicare population were conducted using the Merative MarketScan Commercial Database and Medicare Standard Analytic File (5% sample), respectively. Patients aged 18+ were included if they had an encounter in any setting with a primary stone diagnosis or stone procedure (ureteroscopy [URS], percutaneous nephrolithotomy (PCNL), or shockwave lithotripsy [SWL]) between 2011 and 2019. Analyses were conducted at the patient level.

RESULTS

Over the study time horizon, the prevalence of stone disease showed a small yet statistically significant decrease in the commercial population (1.04%-1.01%; P.ß<.ß0.0001) and a statistically significant increase in the Medicare population (1.84%-2.34%; P.ß<.ß0.0001). URS.ßprocedure volumes increased by 22.6% (P.ß<.ß0.0001) in the commercial population and by 56.6% (P.ß<.ß0.0001) in the Medicare population over the study period. Similarly, PCNL.ßprocedure volumes increased by 17.4% (P.ß<.ß0.0001) in the commercial population and 27.5% (P.ß<.ß0.0001) in the Medicare population. Procedure volumes for SWL decreased by 26.9% in the commercial population (P.ß<.ß0.0001) and by 3.8% in the Medicare population although the results were not statistically significant.

CONCLUSION

The prevalence of stone disease showed a small decrease in the US commercial population and an increase in the Medicare population over the study time horizon. In both populations, increasing procedure volumes were observed for URS and PCNL while decreasing volumes were observed for SWL.

Efficacy and safety of surgical treatment for 1-2 cm sized lower pole of renal stone: network meta-analysis of randomized control trials

The management of medium-sized (1-2 cm) lower poles renal stone has been a contentious topic for endourologists. There are limited evidences to answer the best management options for medium-sized lower pole renal stone. This network meta-analysis provided high-level evidences on efficacy and safety of profile of PCNL, Mini-PCNL, Ultra-PCNL, RIRS, Micro-PCNL, SWL for management of medium-sized lower pole renal stone. Systemic review and network meta-analysis (NMA) of randomized control trials was conducted. The PICOS (Population, Interventions, Comparison, Outcomes, and Study) approach was used to look for relevant studies. Searches were conducted at major electronic databases like Medline via PubMed, Embase, Google Scholar, SCOPUS, ScienceDirect, Cochrane library, Web of Science, and ClinicalTrials.gov to find relevant articles from the inception to April 19, 2023. Fourteen randomized control trials involving 2194 patients were among these studies that met the eligibility criteria. Pooled SFR was Mini-PNCL 98% (95% CI 96-99%), Ultara-PCNL 96% (95% CI 93-98%), RIRS 90% (95% CI 88-92%), PCNL 88% (95% CI 85-92%), Micro-PCNL 77% (61-88%) and SWL 69% (95% CI 65-74%). Mini-PCNL provided a statistically significant higher SFR compared to RIRS (RR = 2.43 91.52; 3.89)), Micro-PCNL (RR = 3.19 (1.09; 9.38)), and SWL (RR = 6.17 (3.65; 10.44)), but there was no statistical significance with standard PCNL (RR = 1.06 (0.52; 2.16)) and Ultra-PCNL (RR = 1.37 (0.75; 2.51)) for management of medium-sized lower pole renal stone. The order of SUCRA values for complication rate was as follows: PCNL(90%), Micro-PCNL(70%), Mini-PCNL(50%), Ultra-PCNL(50%), RIRS(40%), and SWL(10%). The current pooled evidence from fourteen randomized control trials revealed that Mini-PCNL, Ultra-PCNL, and standard PCNL are likely the best treatments for medium-sized lower poles when SFR over a short period of minimal session is a priority. These treatment options have a higher rate of complications, longer hospital stays, and acceptable operations time. RIRS and SWL treatment have acceptable efficacy stone-free rate with low complication rate, short hospital stays, and operation time. These treatment option would be the best fit for solitary kidney, coagulopathy, and comorbidity.

Ureteric stent associated spondylodiscitis

This case report describes a clinical presentation of spondylodiscitis, following an emergency ureteric stent placement for an infected and obstructed kidney in a woman in her late 70s who presented with right flank pain, raised inflammatory markers and an acute kidney injury. Non-contrast CT kidney, ureters and bladder (KUB) revealed a 9 mm obstructing stone and prompt decompression with a JJ stent was performed. Although the urine culture showed no growth at first, an extended spectrum beta-lactamase Escherichia coli was found in a subsequent urine culture after discharge. Postoperatively, the patient described a novel, worsening lower back pain and had persistently elevated inflammatory markers. An MRI revealed spondylodiscitis of L5/S1, for which she was treated with a 6-week course of antibiotics, and she has made a good but slow recovery. This case shows the unusual finding of spondylodiscitis postureteric stent placement and clinicians should be aware of this rare complication.

Innovations in endourologic stone surgery: contemporary practice patterns from a global survey

OBJECTIVE

The purpose of this study is to evaluate the current availability of technology for urolithiasis treatment and ureteroscopy. Perioperative practice patterns, availability of ureteroscopic technologies, pre- and post-stenting practices, and methods to alleviate stent-related symptoms were assessed via a survey of members of the Endourological Society. Methods We distributed a 43-question survey online via the Qualtrics platform to members of the Endourological Society. The survey consisted of questions pertaining to the following topics: general (6), equipment (17), preoperative ureteroscopy (URS; 9), intraoperative URS (2), and postoperative URS (9). Results A total of 191 urologists responded to the survey. 51% of urologists were fellowship trained and dedicated an average of 58% of their practice to stone management. In terms of procedures, most urologists performed ureteroscopy most commonly (68%), followed by percutaneous nephrolithotomy (23%) and shockwave lithotripsy (11%). 90% of respondent urologists purchased a new ureteroscope within the last five years (16% single-use scopes, 53% reusable, and 31% purchased both). 57% of the respondents stated that they would be interested in a ureteroscope that can sense intrarenal pressure, with an additional 30% stating they would be interested depending on the cost. 80% of responders purchased a new laser within the last five years, and 59% changed their lasering technique due to the new laser. 70% are performing primary ureteroscopy for obstructing stones, and 30% prefer pre-stenting patients for subsequent URS (on average after 21 days). 59% of responders insert a ureteral stent after URS, which is removed, on average, after eight days in uncomplicated cases and 21 days after complicated URS. Most urologists give analgesics, alpha-blockers, and anticholinergics for stent-related symptoms and less than 10% prescribe opioids. Conclusion Our survey revealed urologists' eagerness for the early adoption of novel technologies and adherence to conservative practice patterns focused on patient safety.

Factors Associated With Urolithiasis: A Hospital-Based Case-Control Study

BACKGROUND

Urolithiasis is a common preventable ailment. Previous studies showed that there are a lot of factors, such as dietary, health and environmental factors, which are likely to develop this condition. Only a few research have been conducted on urolithiasis in the UAE. Therefore, our study aimed to identify the factors associated with urolithiasis in the country, identify the symptoms of urolithiasis among the cases and identify the most common diagnostic methods.

METHODOLOGY

It was a case-control study design. The study population was adults above 18 years attending a tertiary care centre. Those who have confirmed diagnosis of urolithiasis and gave informed consent were considered cases and those who have not confirmed diagnosis of urolithiasis as controls. Patients with renal, bladder or urinary tract impairment or anomaly were excluded from the study. Ethical approval was obtained for the study.

RESULTS

Crude odds ratio (OR) showed that age, gender, past treatment for urinary stones, and lifestyle factors such as diet and smoking are risk factors while exercising is a protective factor. Age-adjusted OR found that past treatment for the urinary disease (OR=10.4), consumption of oily food (OR=11.5), consumption of fast food (OR=11.0) and consumption of energy drinks (OR=5.9) were the significant risk factors for urolithiasis.

CONCLUSION

We found that past urinary disease treatment and diet are vital in developing urinary stones. Higher consumption of salty, oily, sugary and protein foods increases the odds of urinary diseases. Public awareness programs are essential to educating people about urolithiasis risk factors and preventive measures.

Development and validation of a predictive model for major complications after extracorporeal shockwave lithotripsy in patients with ureteral stones: based on a large prospective cohort

The risk factors of complications after SWL are not well characterized. Therefore, based on a large prospective cohort, we aimed to develop and validate a nomogram for predicting major complications after extracorporeal shockwave lithotripsy (SWL) in patients with ureteral stones. The development cohort included 1522 patients with ureteral stones who underwent SWL between June 2020 and August 2021 in our hospital. Five hundred and fifty-three patients with ureteral stones participated in the validation cohort from September 2020 to April 2022. The data were prospectively recorded. Backward stepwise selection was applied using the likelihood ratio test with Akaike's information criterion as the stopping rule. The efficacy of this predictive model was assessed concerning its clinical usefulness, calibration, and discrimination. Finally, 7.2% (110/1522) of patients in the development cohort and 8.7% (48/553) of those in the validation cohort suffered from major complications. We identified five predictive factors for major complications: age, gender, stone size, Hounsfield unit of stone, and hydronephrosis. This model showed good discrimination with an area under the receiver operating characteristic curves of 0.885 (0.872-0.940) and good calibration (P = 0.139). The decision curve analysis showed that the model was clinically valuable. In this large prospective cohort, we found that older age, female gender, higher Hounsfield unit, size, and grade of hydronephrosis were risk predictors of major complications after SWL. This nomogram will be helpful in preoperative risk stratification to provide individualized treatment recommendations for each patient. Furthermore, early identification and appropriate management of high-risk patients may decrease postoperative morbidity.

Temporary Incapacitation Rates and Permanent Loss of Medical License in Commercial Airline Pilots

INTRODUCTION: The purpose of this study was to report the temporary loss of medical license and pilot incapacitations in the United Arab Emirates from 2018-2021.METHOD: The General Civil Aviation Authority database was searched for all reported temporary suspensions of license between 2018-2021 and the ICD-10 codes were extracted.RESULTS: A total of 1233 incapacitations was reported with a mean license suspension of 148.4 ± 276.8 d. The mean days of suspension for the various medical specialties were 115.2 ± 188.4 for musculoskeletal conditions (N = 392), 189.3 ± 324.8 for medicine (N = 335), 101.6 ± 231.4 for surgery, 109.4 ± 223.5 for urology (N = 93), 90.3 ± 128.7 for ophthalmology (N = 68), 385.6 ± 594.3 for psychiatry (N = 61), 150.4+285.9 for ENT (N = 59), 419.4 ± 382.6 for obstetrics and gynecology (N = 30), and 44.9+39 for dermatology (N = 21). Permanent suspensions were as follows: total N = 100 (8.1%), musculoskeletal N = 13 (3.3%), medicine N = 37 (11%), surgery N = 10 (5.7%), urology N = 10 (10.7%), ophthalmology N = 2 (2.9%), psychiatry N = 20 (32.8%), ENT N = 1 (1.7%), obstetrics and gynecology N = 4 (13.1%), and dermatology N = 3 (14.3%).DISCUSSION: Musculoskeletal conditions are the most common reason for temporary loss of medical license followed by medical and surgical conditions. The least common reason was dermatological conditions. The longest period of incapacitation was associated with psychiatric conditions followed by medical and ENT conditions. The annual calculated temporary incapacitation rate was 2.8% and the permanent suspension rate was 0.25%.Hohmann E, Pieterse R. Temporary incapacitation rates and permanent loss of medical license in commercial airline pilots. Aerosp Med Hum Perform. 2023; 94(3):113-121.

Education and training evolution in urolithiasis: A perspective from European School of Urology

Objective

With the worldwide increase in urolithiasis prevalence, the present study aimed to delineate and summarise recent evolutions in training for the management of urolithiasis.

Methods

A PubMed search using the key words "simulation", "training", "ureteroscopy", "RIRS", "URS", "percutaneous nephrolithotomy", "PCNL", "virtual reality", "augmented reality", "artificial intelligence", "healthcare", "curriculum", and "assessment" was used to examine how education and training in urolithiasis have adapted over recent years. Focus was placed on the role of high- and low-fidelity simulation models, virtual reality and artificial intelligence, and standardised assessment and curriculum.

Results

This review supports the necessity to incorporate technology, simulation, and other skill enhancement training modalities into surgical training. However, these cannot solely replace mentored training with an experienced professional supervisor. Whilst technological and simulation advancements are likely to prove increasingly important in urolithiasis training, it is just as important for stratification of robust curricula with validated assessment. We also propose a pathway for future training.

Conclusion

Endourology subspeciality training programmes have successfully incorporated simulation model-based training for skill acquisition, refinement, and improving operative outcomes. Success is achieved by maintaining a delicate balance between machine and in person mentor-based training. A trainee-centred model that follows the proposed curriculum could aid this balance for the future generation of trainees.

Global, Regional, and National Incidence and Disability-Adjusted Life-Years for Urolithiasis in 195 Countries and Territories, 1990-2019: Results from the Global Burden of Disease Study 2019

Purpose: Urolithiasis is highly prevalent worldwide. The aim of this study was to report the results of the Global Burden of Disease 2019 study on urolithiasis burden estimates grouped by gender, regions, countries or territories, and sociodemographic index (SDI) from 1990 to 2019 globally. Methods: We reported detailed estimates and temporal trends of the burden estimates of urolithiasis from 1990 to 2019 in 195 countries and territories and further evaluated the relationship between these estimates and SDI, a composite indicator of income per person, years of education, and fertility as a measurement of country/region socio-economic level. Urolithiasis incidence and disability-adjusted life years by gender, regions, countries or territories, and SDI were reported. The percentage change and estimated annual percentage change of these burden estimates were calculated to quantify temporal trends. Results: From 1990 to 2019, the age-standardized incidence rate (ASIR) and disability-adjusted life years (DALYs) of urolithiasis decreased globally by 0.459% and 1.898% per year, respectively. Such a trend of ASIR was prominently due to the decline in the middle, high-middle, and high SDI countries, including Eastern Asia, high-income Eastern Europe, and high-income North America. During this period, these estimates increased in low and low-middle SDI countries, particularly in South Asia, Andean Latin America, and Western Europe. A decline in DALYs was observed in all SDI countries. An approximate positive linear association existed between the burden estimate's decreased APC and SDI level, except at the high SDI level. Both males and females showed the same trend. Conclusions: This study provides comprehensive knowledge of the burden estimate of urolithiasis. Although the burden estimates of urolithiasis showed a global decrease during the past 29 years, this progress has yet to be universal; the increasing trends were observed in countries with low and low-middle SDI countries. Research in these countries is needed and helps with the appropriate allocation of health resources for prevention, screening, and treatment strategies.

Heatwave and urinary hospital admissions in China: Disease burden and associated economic loss, 2014 to 2019

BACKGROUND

Many studies have shown that heatwaves are associated with an increased prevalence of urinary diseases. However, few national studies have been undertaken in China, and none have considered the associated economic losses. Such information would be useful for health authorities and medical service providers to improve their policy-making and medical resource allocation decisions.

OBJECTIVES

To explore the association between heatwaves and hospital admissions for urinary diseases and assess the related medical costs and indirect economic losses in China from 2014 to 2019.

METHODS

Daily meteorological and hospital admission data from 2014 to 2019 were collected from 23 study sites with different climatic characteristics in China. We assessed the heatwave-hospitalization associations and evaluated the location-specific attributable fractions (AFs) of urinary-related hospital admissions due to heatwaves by using a time-stratified case-crossover method with a distributed lag nonlinear model. We then pooled the AFs in a meta-analysis and estimated the national excess disease burden and associated economic losses. We also performed stratified analyses by sex, age, climate zone, and urinary disease subtype.

RESULTS

A significant association between heatwaves and urinary-related hospital admissions was found with a relative risk of 1.090 (95 % confidence interval (CI): 1.050, 1.132). The pooled AF was 8.27 % (95%CI: 4.77 %, 11.63 %), indicating that heatwaves during the warm season (May to September) caused 248,364 urinary-related hospital admissions per year, with 2.42 (95%CI: 1.35, 3.45) billion CNY in economic losses, including 2.23 (95%CI: 1.29, 3.14) billion in direct losses and 0.19 (95%CI, 0.06, 0.31) billion in indirect losses, males, people aged 15-64 years, residents of temperate continental climate zones, and patients with urolithiasis were at higher risk.

CONCLUSION

Tailored community health campaigns should be developed and implemented to reduce the adverse health effects and economic losses of heatwave-related urinary diseases, especially in the context of climate change.

Comparison of Surgical Outcomes between Single-Use and Reusable Flexible Ureteroscopes for Renal Stone Management: A Systematic Review and Meta-Analysis

Background and Objectives: Disposable flexible ureteroscopes have been widely used because of their cost-effectiveness and higher sterility potential compared with reusable flexible ureteroscopes. This study aimed to compare the surgical outcomes and complication rates in patients who undergo reusable or disposable flexible ureteroscopic stone surgeries (fURS) for urinary stone disease. Materials and Methods: A systematic review and meta-analysis were conducted under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. This systematic review was registered with PROSPERO (CRD42022331291). Clinical trials comparing reusable and disposable fURS for stone disease were found from PubMed, EMBASE, Cochrane Library, and the Web of Science up to March 2022. Participants were patients with upper urinary tract stones; the interventions were reusable or disposable fURS. Outcomes, including stone-free rate, operation time, length of hospital stay, and complication rate, were compared for analysis. Results: Overall, 111 studies were identified, but after removing duplicate studies, 75 studies remained. Thirty-two of these studies were excluded. Of the 43 screened studies, 11 met the eligibility criteria. There was no difference in the stone-free rate (SFR) between disposable and reusable fURS (p = 0.14; OR = 1.36; 95% CI, 0.9 to 2.04). For operation time, no difference was identified between reusable and disposable fURS groups (p = 0.12; MD = -5.31; 95% CI, -12.08 to 1.46). For hospital stay, there was also no difference between the two groups (p = 0.61; MD = -0.03; 95% CI, -0.17 to 0.10). There was no significant difference in complication rate between the two groups (p = 0.85; OR = 0.95; 95% CI, 0.56 to 1.61). Conclusions: There were no differences in the SFR, operation time, length of hospital stay, and complication rate between reusable and disposable fURS. Disposable fURS may be a comparable alternative to reusable fURS.

Shock Wave Lithotripsy Outcomes for Upper and Lower Ureteral Stones in Non-obese and Non-Pre-stented Adults: Is One Session Sufficient?

Purpose

This study aims to evaluate differences in shock wave lithotripsy (SWL) outcomes between upper and lower ureteral stones and identify patients who are likely to have a stone-free status after one session of SWL.

Materials and methods

After approval from the institutional review board and from a prospectively maintained database of 628 patients, 182 were retrospectively identified, who have had SWL for a single lower or upper ureteral stone and met the inclusion criteria. Age, body mass index (BMI), and stone size were similar among the groups. This study included non-pre-stented patients with solitary lower or upper ureteral radiopaque stones identified on non-contrast-enhanced computed tomography (NCCT), did not have acute obstruction, and had either normal body mass index (BMI) or overweight status. Patients were treated with Sonolith i-sys electroconductive lithotripter (focal length: 21 cm) (EDAP TMS, Vaulx‐en‐Velin, France). Success was defined as the absence of residual of any size or a residual of ≤2 mm on NCCT after one month, whereas failure was having fragments >2 mm or requiring surgical intervention. Post-SWL assessments were completed one week after every session with an X-ray of the kidney-ureter-bladder (KUB-XR) and NCCT after one month.

Results

The upper and lower ureteral stone-free rates (SFRs) were 95% and 64.7%, respectively. Of them, 65% and 45%, respectively, were stone-free after one session. The cohort having a stone-free status after one SWL session was similar in age, sex, BMI, and stone density. The upper ureteral stone arm has a significant chance for one SFR session with a larger stone size, shocks per session, and maximum power delivered. In the receiver operating characteristic (ROC) curves, the optimal cut point number of sessions of 1.5, mean stone density (MSD) of 895, and stone size of 10.5 mm are the most likely to have successful SWL in the ureter.

Conclusion

For patients having ureteral stones with favorable factors, SWL modality is effective and safe. Moreover, SWL can be done for one or two sessions only with the presence of favorable factors.

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.

Metabolic evaluation: is there really a future?

PURPOSE OF REVIEW

To confirm the need for a metabolic evaluation in stone formers based on the latest information published in the last 24 months and in the current 2022 American and European urological guidelines.

RECENT FINDINGS

Recent studies suggest that urolithiasis prevalence has been increasing since 1990. Along with it, metabolic abnormalities that contribute to the development of kidney stones are also increasing, such as hyperuricosuria, hyperoxaluria, hypocitraturia, hypomagnesuria, hypocalciuria, hypophosphaturia, and hyperuricemia. Those abnormalities can only be detected through a metabolic evaluation in patients with stone disease.

SUMMARY

It is important for us, urologists, to have in mind the actual stone prevalence worldwide. As part of our initial evaluation of the patient with urolithiasis, we must not forget to perform the basic metabolic analysis and, according to the patient's risk classification, continue with a deep metabolic analysis. This extensive analysis includes blood and urine tests. The urinalysis covers 24-h urinalysis, and it would be accurate to also have an early fresh urine analysis. Moreover, identifying the stone type is intimately correlated with the search for other metabolic parameters.