Is "Kidney Stone Calculator" efficient in predicting ureteroscopic lithotripsy duration? A holmium:YAG and thulium fiber lasers comparative analysis

PURPOSE

This study aimed to evaluate the ability of Kidney Stone Calculator (KSC), a flexible ureteroscopy surgical planning software, to predict the lithotripsy duration with both holmium:YAG (Ho:YAG) and thulium fiber laser (TFL).

METHODS

A multicenter prospective study was conducted from January 2020 to April 2023. Patients with kidney or ureteral stones confirmed at non-contrast computed tomography and treated by flexible ureteroscopy with laser lithotripsy were enrolled. "Kidney Stone Calculator" provided stone volume and subsequent lithotripsy duration estimation using three-dimensional segmentation of the stone on computed tomography and the graphical user interface for laser settings. The primary endpoint was the quantitative and qualitative comparison between estimated and effective lithotripsy durations. Secondary endpoints included subgroup analysis (Ho:YAG-TFL) of differences between estimated and effective lithotripsy durations and intraoperative outcomes. Multivariate analysis assessed the association between pre- and intraoperative variables and these differences according to laser source.

RESULTS

89 patients were included in this study, 43 and 46 in Ho:YAG and TFL groups, respectively. No significant difference was found between estimated and effective lithotripsy durations (27.37 vs 28.36 min, p = 0.43) with a significant correlation (r =  + 0.89, p < 0.001). Among groups, this difference did not differ (p = 0.68 and 0.07, respectively), with a higher correlation between estimated and effective lithotripsy durations for TFL compared to Ho:YAG (r =  + 0.95, p < 0.001 vs r =  + 0.81, p < 0.001, respectively). At multivariate analysis, the difference was correlated with preoperative (volume > 2000 mm3 (Ho:YAG), 500-750 mm3 SV and calyceal diverticulum (TFL)), operative (fragmentation setting (p > 0.001), and basket utilization (p = 0.05) (Ho:YAG)) variables.

CONCLUSION

KSC is a reliable tool for predicting the lithotripsy duration estimation during flexible ureteroscopy for both Ho:YAG and TFL. However, some variables not including laser source may lead to underestimating this estimation.

Risk assessment and prevention of urolithiasis in urban areas of Baoding, China

Urolithiasis, or the formation of calculi in the urinary system, represents a prevalent urological condition frequently encountered among individuals aged 30 to 55 years. An in-depth analysis of the composition of these calculi holds significant promise in shedding light on the underlying etiological and pathogenic factors contributing to this ailment. The primary objective of this study was to delineate the principal components comprising urinary system calculi within a cohort of patients who sought medical intervention at a tertiary grade A hospital located in Baoding City. Furthermore, our investigation entailed a comprehensive examination of the physical and morphological characteristics exhibited by these calculi. In this study, a total of 2307 individuals afflicted with urinary system calculi were recruited as participants, and a corresponding number of 2307 calculous specimens were subjected to thorough examination. The specimens were examined using infrared spectroscopy. We collected and examined patient data including gender, age, location of the calculi, employment status, residential area, and other factors. The middle-aged demographic exhibited a conspicuous predilection for urinary system calculi, wherein a notable gender disparity was observed, with a male-to-female ratio of 1.63 to 1. Among the enrolled patients, kidney calculi were prevalent in 1270 cases, ureteral calculi were documented in 983 cases, and bladder calculi were encountered in 46 instances. Notably, the principal components comprising these calculi were identified as calcium oxalate and apatite, while uric acid and ammonium magnesium phosphate were comparatively less frequently encountered. Furthermore, the analysis of calculus composition across patients residing in distinct geographical regions did not reveal any statistically significant variations. The identification of components within upper urinary tract calculi plays a pivotal role in elucidating the root causes of calculus formation. This valuable information empowers healthcare professionals, particularly nursing staff, to provide personalized dietary and health guidance to patients, thereby enhancing the quality of care and promoting more effective management of this condition.

Evaluating the performance of ChatGPT in answering questions related to urolithiasis

PURPOSE

ChatGPT is an artificial intelligence (AI) program with natural language processing. We analyzed ChatGPT's knowledge about urolithiasis whether it can be used to inform patients about urolithiasis.

METHODS

Frequently asked questions (FAQs) about urolithiasis on the websites of urological associations and hospitals were analyzed. Also, strong recommendation-level information was gathered from the urolithiasis section of the European Association of Urology (EAU) 2022 Guidelines. All questions were asked in order in ChatGPT August 3rd version. All answers were evaluated separately by two specialist urologists and scored between 1 and 4, where 1: completely correct, 2: correct but inadequate, 3: a mix of correct and misleading information, and 4: completely incorrect.

RESULTS

Of the FAQs, 94.6% were answered completely correctly. No question was answered completely incorrectly. All questions about general, diagnosis, and ureteral stones were graded as 1. Of the 60 questions prepared according to the EAU guideline recommendations, 50 (83.3%) were evaluated as grade 1, and 8 (13.3%) and 2 (3.3%) as grade 3. All questions related to general, diagnostic, renal calculi, ureteral calculi, and metabolic evaluation received the same answer the second time they were asked.

CONCLUSION

Our findings demonstrated that ChatGPT accurately and satisfactorily answered more than 95% of the questions about urolithiasis. We conclude that applying ChatGPT in urology clinics under the supervision of urologists can help patients and their families to have better understanding on urolithiasis diagnosis and treatment.

Acute Pelvic Pain: Role of Imaging in the Diagnosis and Management

Acute pelvic pain is defined as a new symptom that has been present for less than 3 months. It is a common symptom seen in 15%-24% of women and is the indication for 20% of laparoscopies and 2%-10% of outpatient gynecologic visits. The pregnancy status and correlation of the physical symptoms with clinical findings are important. Ultrasound is the imaging modality of choice, not only to diagnose gynecological causes, but also bowel or urinary tract related causes of pelvic pain. When an ultrasound scan is inconclusive, a computed tomography scan is the preferred means of additional imaging and is particularly useful in gastrointestinal and urogenital causes of pelvic pain. Gynecological causes of acute pelvic pain include uterine, tubal, or ovarian pathology; non-gynecological causes include bowel diseases, such as appendicitis and diverticulitis; urogenital causes such as ureteral, bladder stones, and urinary tract infection as well as vascular causes. Ultrasound imaging alone may provide a definitive diagnosis in underlying conditions that require prompt medical or surgical intervention in gynecological conditions, such as ovarian torsion, ectopic pregnancy, and non-gynecological condition, such as in acute appendicitis.

[Effects of delayed ureteral stents removal during the COVID-19 pandemic on the quality of life and psychological status of postoperative patients with urinary calculi]

OBJECTIVE

To explore the impacts of delayed ureteral stent removal on the quality of life (QoL) and mental health of urinary calculi postoperative patients due to the corona virus disease 2019(COVID-19) pandemic.

METHODS

The demographic and clinical data of patients with ureteral stent placement after urinary endoscopic lithotripsy and returned to Peking University People's Hospital for stent removal from December 2019 to June 2020 were collected. Ureteral stent symptoms questionnaire (USSQ) score and the outcome 20-item self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were collected to estimate the QoL and mental status. The USSQ consisted of 44 questions in 6 domains (including urinary symptom, physical pain, general health, work performance, sexual function, and ureteral stent related infection). For most questions in each domain, its score was a five-point Likert-type scale from 1 to 5, and a small proportion of questions was quantified by 1 to 4 or 1 to 7 scale. SAS and SDS both contained 20 questions used to assess a patient's level of anxiety and depression. Its scoring for each item was on a four-point Likert-type scale from 1 to 4. A total score (ranging from 20 to 80) was the main statistical indicator. The level of clinical anxiety and depression was quantified by using standard scores (total score multiplied by 1.25 to produce integers). And the multi-group structural equation model was constructed by analysis of moment structure (AMOS) analysis.

RESULTS

Overall, 71 patients were enrolled for analysis. It was found that the median duration of ureteral stent time differed significantly between the control and delayed groups for 32 (30, 33) d and 94.5 (88, 103) d, respectively. The delayed group resulted in higher scores in the USSQ multidimensional, which included urinary symptoms, general health, work performance and ureteral stent related infections. Anxiety and depression were also significantly serious in the delayed group than in the control group. A longer indwelling time of a ureteral stent could exacerbate the effects of urinary symptoms and physical pain on work performance (P=0.029 < 0.05). Among them, the patients with severe urinary symptoms leading to poor work performance were most significantly affected by prolonged ureteral stent duration time (CR=2.619>1.96).

CONCLUSION

Patients with delayed ureteral stent removal due to the COVID-19 had resulted in worse QoL and mental status. Stents related symptoms are more severe in patients with higher anxiety and depression degree during COVID-19. To improve the QoL and mental health of patients after urinary calculi surgery during COVID-19, it is still not recommended to prolong the stent duration time or corresponding intervention measures should be taken.

The Patient Voice: Stent Experiences After Ureteroscopy-Insights from In-Depth Interviews with Participants in the USDRN STENTS Nested Qualitative Cohort Study

Purpose: Ureteral stents are commonly used after ureteroscopy and cause significant discomfort, yet qualitative perspectives on patients' stent experiences remain unknown. We describe psychological, functional, and interpersonal effects of post-ureteroscopy stents and whether additional patient-reported assessments may be needed. Materials and Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with a nested cohort of participants in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS). Participants shared their symptoms with a post-ureteroscopy stent and described symptom bother and impact on daily activities. All interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. During analysis, participants' experiences with interference in daily activities were categorized into three groups based on their impact: minimal, moderate, and substantial. Results: All 39 participants experienced pain, although descriptions varied and differentiated between feelings of pain vs discomfort. Almost all experienced urinary symptoms. Only a few reported other physical symptoms, although several psychological aspects were identified. In the areas of sleep, mood, life enjoyment, work, exercise, activities of daily living, driving, childcare, and leisure/social activities, the stent had little impact on daily living among participants placed in the minimal group (n = 12) and far greater impact for participants in the substantial group (n = 8). For patients in the moderate group (n = 19), some daily activities were moderately or substantially affected, whereas other activities were minimally affected. Conclusions: Counseling to better prepare patients for the impact of stent-associated symptoms may help mitigate symptom burden. While existing instruments adequately cover most symptoms, additional assessments for other domains, particularly psychological factors, may be needed.

Imaging of ureter: a primer for the emergency radiologist

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Comparison of current guidelines on medical management of stone disease

OBJECTIVE

The objective of this study isto present the content of existing Guidelines on medical management of urinary stone disease.

MATERIALS AND METHODS

A search for current Guidelines from national and international urological Associations was performed in Societe International d'Urologie and American Urological Association websites, along with a search in Pubmed/MEDLINE until 30/06/2020. Two authors performed an independent search and data extraction regarding medical management of acute renal colic, medical expulsive treatment, dietary modifications and pharmaceutical interventions for prevention of stone disease recurrence. Quality of Guidelines was assessed by the two reviewers using the AGREE II instrument.

RESULTS

Literature search revealed 82 Associations, while eight of them provide recommendations/Guidelines on medical management of stone disease. Non-steroidalanti-inflammatory drugs or paracetamol are the most common 1st line treatment proposed for acute pain management, with opiates following next. Use of a-blockers is also indicated by most Guidelines for facilitating expulsion of distal ureteral stones 5-10 mm, after shockwave or laser lithotripsy or for alleviating stent-related symptoms. Adequate fluid in take, normal dietary calcium consumption and sodium restriction with varying daily limits, are universal dietary modifications from urological Associations on prevention of stone disease. Thiazidesand alkaline citrates are proposed usually for calciumoxalate stone formers with differences in grading of the recommendations, while urinary alkalization with allopurinol or febuxostat as a second line treatment is acommon treatment algorithm for urate stones, but with differences in target urine pH. European and American Urological Association Guidelines, along with National Institute for Health and Care Excellence recommendations were the most highly rated based on AGREE II.

CONCLUSIONS

Despite methodological heterogeneity and subjective rating of recommendations, an acceptable degree of consensus was noted on Guidelines regarding medical management of stone disease.

[Risk factors for complications of ureterolithotripsy]

AIM

to determine main risk factors for complications of ureterolithotripsy.

MATERIALS AND METHODS

a retrospective analysis of the results of 545 ureteroscopies performed in 506 patients with ureteral stones over the past 7 years at the urological clinic named after M.F. Vladimirsky was carried out. The relationship between preoperative and intraoperative factors and complications of ureterolithotripsy was analyzed.

RESULTS

The overall complication rate was 22.4%. The risk of intraoperative complications was proved to increase (p<0.05) along with the stone size, location in proximal ureter, stone impaction for more than 3 weeks and the degree of hydronephrosis. No preoperative stenting or nephrostomy tube prior to ureteroscopy was associated to an increased risk of intraoperative complications (RR=2.88; p=0.03). Patients with preoperative drainage of upper urinary tract has lower probability of intraoperative complications (OR=0.35; p=0.03). The risk of developing stricture and ureteral obliteration in uncomplicated ureteroscopy was minimal (RR=0.008, p=0.0001). Small ureteral perforation and pronounced mucosal inflammation around the stone have the similar influence on the risk of complications, which was more than 7.5 times (p=0.0001) higher than in uncomplicated ureteroscopy. Large ureteral perforation was associated with the highest risk of stricture formation and ureteral obliteration, which was 64 times (p=0.0001) higher than in uncomplicated ureteroscopy.

CONCLUSION

The rate of complications of ureterolithotripsy directly depends on the following factors: size and location of the stone, the stone impaction, pre- and intraoperative (nephrostomy tube) drainage of the upper urinary tract, the degree of hydronephrosis, level of bacteriuria and intraoperative trauma complications.

[Autologous kidney transplantation after ureter avulsion during ureterolithotripsy]

Currently, when performing ureterolithotripsy in patients with proximal ureteral stones, urologist should be ready for intraoperative complications and be able to use various methods to diagnose them. Ureteral avulsion is an extremely rare, but the most serious complication of endoscopic procedures. Clinical observation of autologous kidney transplantation performed after ureteral avulsion with good functional and clinical results is presented.

[Comparison of the composition of DJ tube encrustation and original stone and analysis of its causes]

Objective: To compare the composition of DJ tube encrustation and original stone, and to discuss the causes and prevention of encrustations. Methods: Twenty-five patients with DJ tube encrustation (1 case of INLAY OPTIMA(®) tube, Bard Medical, 16 cases of Universa(®) Firm tube, Cook Medical, 8 cases of Polaris™ Loop tube, Boston Scientific) in our institution from Januarry 2018 to April 2019 wereretrospective analyzed. Stones and encrustations were analyzed using the Fourier transform infrared spectroscopy analysis system to compare the differences in composition. Results: 76% (19/25) patients had the exact same DJ tube encrustations composition as the original stone component; 24% (6/25) patients had DJ tube encrustation and original stone composition inconsistent (5 cases of calcium oxalate stone, 1 case of apatite carbonate.) It maybe related to the control of urinary tract infection after ureteral obstruction. The earliest DJ tube with encrustation was a pre-expansion tube before flexible-ureteroscopy, and the indwelling time was only 18 days. Conclusions: DJ tubes of different brands and models have the risk of formation of encrustation. Most of the encrustation has the same composition as the original stone. The prevention of DJ tube scorpion can be started from: (1) removing the DJ tube within 6 weeks or replace it regularly when necessary; (2) selecting the appropriate tube including diameter and model; (3) actively controlling urinary tract infection; (4) treating the metabolic diseases, such as hypercalcemia, hyperuricemia, et al, and providing personalized guidance for each patient.

[Retroperitoneoscopic approach for treatment of acute obstructive calculous pyelonephritis. Alternative or a method of choice?]

AIM

to compare the results of treatment of patients with acute obstructive calculous pyelonephritis, who underwent to retroperitoneoscopic procedure, with patients, who underwent to drainage of the collecting system by means of ureteral stent or nephrostomy tube as the first stage.

MATERIALS AND METHODS

A total of 121 patients were treated from 2011 to 2019. Of these, 78 patients were included in the main group. The stones were located in the ureteropelvic junction (n = 20) and the upper and middle ureter (n = 58). The average size of the stone was 12.9 +/- 4.8 mm. Preliminary upper urinary tract drainage was not carried out and the stone was removed completely. The group 2 consisted of 26 people. The stones were located in the upper (n = 18) and the middle ureter (n = 8); the average size was 9 +/- 2.8 mm. Renal drainage was done using ureteral stent and when pyelonephritis resolved, ureterolithotripsy was performed. The group 3 was represented by 17 patients. All stones were located in the ureteropelvic junction. The average size was 20.3 +/- 10.7 mm. Renal drainage was done using percutaneous nephrostomy; when there were no inflammatory changes, percutaneous nephrolithotripsy was performed.

RESULTS

In the main group, normalization of body temperature and resolution of inflammatory changes in the blood and urine occurred earlier. The stone was removed completely and there were no residual fragments. Period of rehabilitation was are also significantly shorter than in groups 2 and 3. The retroperitoneoscopic method was more effective and safer for the treatment of patients with acute obstructive pyelonephritis caused by large stones located in the upper or middle ureter and ureteropelvic junction.

[Dual-energy computed tomography in the diagnostics of urolithiasis]

THE AIM

To assess the diagnostic performance of dual-energy computed tomography (DECT) in the evaluation of the composition of urinary stones "in vivo".

MATERIALS AND METHODS

A total of 91 patients aged from 20 to 70 years old (mean 42.7) with urinary stone disease were examined at Sechenov University, including 68 men (75%) and 23 women (25%). Prior to surgery, all patients underwent DECT (Canon, Japan) in order to predict the chemical composition of urinary stones in vivo. Extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) was performed in 53 (58.2%), 18 (19.7%) and 20 (22.1%) patients, respectively. Postoperatively, all stones or stone fragments (n=91; 100%) were examined using a comprehensive physical and chemical analysis (X-ray phase analysis, electron microscopy, infrared spectroscopy).

RESULTS

In 6 patients (6.6%) staghorn stones were diagnosed, while in 15 (16.5%), 17 (18.7%), 22 (24.2%) and 31 (34.1%) stones were located in ureteropelvic junction, pelvis and ureter, respectively, including 24 patients with lower ureteric stones (26.4%). Prediction of the stone composition in vivo was carried out on the basis of the one indicator, the dual energy ratio (DER). The threshold values of DER for different types of stones were taken from the literature. All stones were divided into 4 groups according to the DECT results: vevellite stones (n=40, 43.9%), Ca-containing stones without vevellite (n=34, 37.3%), uric acid stones (n=10, 10.9%) and struvite stones (n=7, 7.9%). Thus, when comparing the results of DECT and physical and chemical analysis, in the first group four stones were incorrectly assigned by DECT to the group of Ca-containing stones without vevellite and three stones were incorrectly assigned to the group of struvite stones; in the second group four stones were incorrectly assigned to the group of vevellite stones; in the third group one stone was incorrectly assigned to the group of struvite stones; in the fourth group one stone was incorrectly assigned to the group of vevellite stones and one stone in the group of uric acid stones. In order to increase the diagnostic efficiency of DECT, we performed a comprehensive analysis of five specific DECT indicators (stone density at 135 kV, Z eff of the stone, DER, DEI, DED) using discriminant analysis. Thus, the sensitivity, specificity and overall accuracy of DECT with the use of just one indicator (DER) were 83.3%, 89.8%, 86.8% for vevellite, 88.2%, 92.9%, 91.2% for Ca-containing stones without vevellite, 90%, 98.8%, 97.8% for uric acid stones and 60%, 95.3%, 93.4% for struvite stones, respectively. When using discriminant analysis with five specific DECT indicators, higher values of sensitivity, specificity and overall accuracy were seen: 95.2%, 89.8%, 92.3% for a vevellite, 85,3%, 96,4%, 92,3% for Ca-containing stones without a vevellite and 100%, 100% and 100% for both uric acid and struvite stones, respectively.

CONCLUSIONS

Dual-energy computed tomography is a highly informative method which allows to perform preoperatively the reliable assessment of the chemical composition. DECT in patients with urinary stone disease allows to optimize the treatment strategy and carry out preventive measures on individual basis, taking into account the stone type.

[3D-technologies in planning and navigation for laparoscopic interventions in patients with renal and ureteric stones]

AIM

to evaluate the possibilities and efficiency of using 3D technologies for the laparoscopic interventions in patients with renal and ureteric stones.

MATERIALS AND METHODS

A retrospective analysis of the results of surgical treatment of patients with renal and ureteric stones performed in the urology clinic of the I.M. Sechenov First Moscow State Medical University of Minzdrav of Russia for the period from January 2012 to December 2017 was carried out. During this period a total of 4958 interventions were done. Among them, 98 laparoscopic (1.97%) surgeries were performed, including nephron-sparing interventions (n=47; 48%), pyelolithotomy (n=15; 15.3%), ureterolithotomy (n=32; 32.65%) and partial nephrectomy (n=4; 4.05 %). The average patients age was 55.76+/-10.5 (29-80) years. There were 51 men (52%) and 47 women (48%). The mean stone density was 1237.6+/-354.6 HU (from 500 to 1913 HU). In 14 (22.9%) cases, nephrostomy tube or ureteric stent had been put before surgery. In addition, 40 (40.8%) patients previously underwent one surgical intervention on the kidneys and 17 patients with urinary stone disease (17.3%) underwent surgery more or equal 2 times. 88 (89.8%) patients had severe concomitant diseases and the most common pathology in 51 (52.0%) patients with urinary stone disease was arterial hypertension. In 11 (11.2%) cases, the interventions were performed in patients with abnormal kidneys, including horseshoe kidney (n=6; 6.1%), duplicated collecting system (n=3; 3.1%) and pelvic kidney (n=2; 2%). In addition to standard preoperative diagnostic methods in 22 cases (22.4%) the 3D-planning and multivariate virtual performing of intervention based on the multidetector computer tomography scan was done using Amira 3D-modeling program. Among these patients, virtual interventions were performed prior to all pyelolithotomy and partial nephrectomy. Intraoperative data of virtual constructions were used by surgeons as navigation. The interventions were performed by seven urologists at the clinic with various experience in laparoscopic surgery.

RESULTS

The mean duration of laparoscopic pyelolithotomy, laparoscopic partial nephrectomy, laparoscopic ureterolithotomy and laparoscopic nephrectomy was 183.2+/-69.6, 201.3+/-35.2 min, 97.6+/-43.7 and 165.4+/-92.3 min, respectively. The minimal blood loss was observed during laparoscopic ureterolithotomy (53.33+/-31.2 ml). During these interventions, in 8 cases (8.16%) a flexible endoscope was used for inspection and complete removal of stones. Intraoperative complications were noted in 6 patients (6.1%). There were 4 conversions to open surgery (4.1%). Postoperative surgical complications were observed in 1 (1%) patient, while non-surgical complications developed in 4 patients (4.1%). There was no mortality.

CONCLUSION

Laparoscopic access for the treatment of patients with urinary stone disease should be used for the treatment of patients with large, long-standing ureteral calculi and patients with kidney stones who have concomitant pathology of kidney or upper urinary tract (UPJ obstruction, kidney tumors) requiring surgical intervention. Laparoscopic access should be considered primarily for the planning of laparoscopic partial nephrectomy and laparoscopic nephrectomy in patients with urinary stone disease. The use of 3D computer-assisted technologies is advisable for patients with urinary stone disease and abnormal kidneys if laparoscopic pyelolithotomy, partial nephrectomy or ureterolithotomy is planned.

Spontaneous upper urinary tract rupture caused by ureteric stones: A prospective high-volume single centre observational study and proposed management

OBJECTIVE

To evaluate incidence, clinical, radiological and laboratory features of spontaneous upper urinary tract rupture (s-UUTR) due to ureteric stones and discuss their management.

METHODS

Out of 1629 patients admitted to the Emergency Department (ED) for renal colic from January 2015 to December 2016 and studied by kidney US and contrast enhanced CT (CECT), 31 patients had a s-UUTR categorized in 3 stages: a) local spread, b) free fluid, c) urinoma. Presentation, therapeutic procedures and outcomes were registered.

RESULTS

S-UUTR is reported in 1.9% of renal colic. The stone was most commonly identified at the vesicoureteric junction (VUJ) (61.3%) and mean (standard deviation, SD) stone size was 5.71 mm (2.31). S-UUTR was most frequently located in a calyx (54.84%). 26 patients (83.87%) had a clinical presentation of a renal colic, 3 cases (9.68%) had an atypical presentation and 2 (6.45%) presented an acute abdomen. In 26 cases a J-J stent (83,87%) was placed, 3 patients underwent primary ureteroscopic lithotripsy (9.67%); in 1 patient (3.23%) a nephrostomy was inserted and in 1 case (3.23%) active surveillance was adopted. Cases who underwent sole urinary derivation were revaluated after 30 days: ureteroscopic lithotripsy was performed in 48.15% of the cases; extracorporeal shock wave lithotripsy in 3.7%; in 22.2% of cases a CT demonstrated the spontaneous expulsion of the stone. 7 patients were lost at follow-up. The patient undergoing an active surveillance spontaneously expelled the stone.

CONCLUSIONS

S-UUTR is a rare radiological sign of a renal colic most commonly located in a calyceal fornix. A high incidence of s-UUTR is caused by small distal ureteral stones in which a spontaneous passage is reasonable. Clinical presentation usually does not arise the suspicion of s-UUTR. In our experience, most patients were actively treated with good results but a conservative approach can be offered in selected cases.

[Treatment of uretero-renal stones with shock wave lithotripsy. Results and complications with the dornier gemini emse 220f-XXP.]

OBJECTIVES

Extracorporeal shock wave lithotripsy is a minimally invasive therapeutic option for the treatment of renal-ureteral lithiasis. The aim of this study was to analyze the results and complications of shock wave extracorporeal lithotripsy treatment with the Dornier Gemini® Generator EMSE 220f-XXP device in patients with renal and ureteral lithiasis.

MATERIAL AND METHODS

Retrospective study including 377 patients with renal or ureteral lithiasis with indication for treatment with extracorporeal shock wave lithotripsy. The following variables were analyzed, age, sex, body mass index, lithiasis size, lithiasis location, presence of urinary diversion, number of lithotripsy sessions, number of shock waves, fluoroscopy time, wave energy, applied focal energy coefficient, efficiency coefficient, lithiasic fragmentation, lithiasic clearance, residual lithiasis, presence of lithiasis and complications. The results were analyzed with SPSS 17.0 considering statistical significance p≤0.05.

RESULTS

Of the 377 patients, 213 were men and 164 women, with a mean age of 51.28 ± 12.77 years. The mean size of the stones in maximum diameter was 11.77 ± 6.13 mm. Lithiasis fragmentation occurred in 81.9% of cases, with a percentage of residual lithiasis after the first session of 58.7% and a total or partial expulsion rate of lithiasis fragments of 68.3%, with global success at the end of sessions of lithotripsy of 69.8%. The overall Efficiency Ratio was 0.42, higher in upper calyx 0.51 and lower in medium calyx 0.35, with significant differences (p<0.05). The only differences were found in relation to the success of lithotripsy treatment (75% versus 64.6%, p=0.02), according to lithiasis size (≤10 mm maximum diameter in comparison to >10 mm). In patients with a DJ catheter there is a higher percentage of residual lithiasis (p=0.006).

CONCLUSIONS

Treatment with extracorporeal lithotripsy in small lithiasis and in well-selected patients obtains good results with a low rate of complications regardless of sex and body mass index.

[Rehabilitation of patients after modern endourological procedures for urolithiasis]

INTRODUCTION

Numerous publications on the successful use of NefraDoz (Stada, Germany) in the metaphylaxis of urolithiasis after extracorporeal lithotripsy, and the prevention and treatment of infectious inflammatory diseases of the lower and upper urinary tracts, served as the rationale for a study aimed to evaluate the effectiveness and safety of long-term use of NefraDoz in patients after transurethral and percutaneous interventions performed for urological diseases.

PATIENTS AND METHODS

The study analyzed results of 116 transurethral and percutaneous endoscopic operations for urolithiasis performed in 62 men and 54 women aged 21 to 84 years from November to December 2017 at the D.D. Pletnev City Clinical Hospital. Depending on the localization of the stones, all patients were divided into three groups: kidney stones (n=68), ureteral stones (n=28), and bladder stones (n=21). In each group, patients were assigned either to receive (study group, n=50) or not to receive (control group, n=66) postoperative NefraDoz, which was administered at a dose of 1 capsule three times daily for one month. Patients in the control group (n=66) received standard antibacterial therapy for one month. The analysis included leukocyturia, 24-hour diuresis, the severity of the symptoms of the disease and the patients quality of life.

RESULTS

The use of NefraDoz after transurethral lower urinary tract procedures, reduced the severity of irritative symptoms, improved the patients quality of life, reduced the number of patients with leukocyturia and increased 24-hour diuresis. The use of NefraDoz after upper urinary tract procedures improved the patients quality of life, reduced the number of patients with leukocyturia and increased 24-hour diuresis, and improved the clearance of residual fragments. There were no adverse events associated with NefraDoz.

CONCLUSIONS

We have proved the advantage of using the NefraDoz complex in the rehabilitation of patients after endourologic procedures.

PURLs: Tamsulosin for patients with ureteral stones?

A 54-year-old man presents to the emergency department with acute onset left flank pain that radiates to the groin. A computed tomography scan of the abdomen/pelvis without contrast reveals a 7-mm distal ureteral stone. He is deemed appropriate for outpatient management. In addition to pain medications, should you prescribe tamsulosin?

Spontaneous passage of ureteral stones in patients with indwelling ureteral stents

INTRODUCTION

To determine rates of spontaneous ureteral stone passage in patients with indwelling ureteral stents, and to identify factors associated with the spontaneous passage of stones while a ureteral stent is in place.

MATERIALS AND METHODS

From our institutional database, we identified patients who underwent ureteroscopic procedures for stone disease between January 1, 2013 and March 1, 2015. We compared the rates of spontaneous stone passage between patients who had previously undergone ureteral stent placement and those who had not. In patients with indwelling stents, multivariate logistic regression was performed to identify factors associated with spontaneous stone passage.

RESULTS

A total of 194 patients met inclusion criteria. Spontaneous stone passage rates were similar in the stented (17/119, 14%) and non-stented (15/75, 20%) groups (p = 0.30). In bivariate analysis of stented patients, smaller stone size (p < 0.001) and distal stone location (p = 0.01) were significantly associated with spontaneous stone passage. Multivariate logistic regression analysis of stented patients showed that only small stone size was significantly associated with the likelihood of stone passage (p = 0.01), whereas stent duration, stone location, and stone laterality were not.

CONCLUSIONS

A small, but clinically significant percentage of ureteral stones pass spontaneously with a ureteral stent in place. Small stone size is associated with an increased likelihood of spontaneous passage in patients with indwelling stents. These findings may help to identify patients who can potentially avoid additional surgical procedures for definitive stone removal after ureteral stent placement.

[Spontaneous renal rupture of fornix due to obstructing urethral stone]

A 53-year-old man was hospitalized due to acute right-sided flank pain. The pain went from right flank to right fossa. A non-contrast computed tomography (CT) of the abdomen showed pronounced stranding, hydronephrosis and proximal hydroureter. A CT urography showed oedema proximally around the right kidney and pyelogram. Due to lack of contrast excretion in the right kidney, initially "white kidney", there was need of an acute JJ-stent placement. No cause of obstruction was found during operation, however, after the stent placement, the patient was completely relieved of pain.

[Retroperitoneal laparoscopic nephrectomy with autotransplantation for severe iatrogenic ureteral injury]

OBJECTIVE

To evaluate the safety and efficacy of retroperitoneal laparoscopic nephrectomy with autotransplantation in cases of severe iatrogenic proximal ureteral damage.

METHODS

From July 2011 to March 2015, two patients, aged 44 (female) and 54 years (male), underwent retroperitoneal laparoscopic nephrectomy and autotransplantation for treatment of severe iatrogenic proximal ureteral injuries. Both injuries were proximal ureteral avulsion during ureterolithotomy with the holmium laser for ureteral calculi. computed tomography angiography (CTA) and computed tomography urography (CTU) was performed in both patients before operation. A 3-port retroperitoneal technique was used for the patients placed in a lateral decubitus position. A retroperitoneal laparoscopic nephrectomy with autotransplantation approach was used in both the patients, and the kidneys were removed to the right iliac fossa. Case 1's kidney was removed through the right Gibson incision, while Case 2's kidney was removed through the left lumbar incision. The renal artery and renal vein were ligated using the Hem-o-lok. The kidneys were taken out quickly from the patients and infused with 4 °C kidney preserving fluid immediately.

RESULTS

The retroperitoneal laparoscopic nephrectomy with autotransplantations was performed 4 hours in Case 1 and 2 years in Case 2 after atrogenic proximal ureteral injuries. Case 2 was associated with dense perinephric and perihilar fibrosis. The procedures were successful, with immediate return of renal function in both the patients. After ex vivo graft preparation, ureteral and vessel length and quality were adequate for transplantation in both the cases. A direct ureterovesical anastomosis was performed in both patients. In the 2 patients, the warm ischemia time was 3 and 5 minutes, the total operation time 185 and 246 minutes, and the estimated blood loss 70 and 200 mL, respectively. No perioperative complications occurred. At the end of the follow-up, the transplanted kidneys were functional, and the patients had returned to their normal activity.

CONCLUSION

Retroperitoneal laparoscopic nephrectomy with autotransplantation is an excellent alternative to nephrectomyor bowel interposition in patients with proximal ureteral loss. This procedure is associated with acceptable morbidity and preserves the renal function. This report supports the safety and efficacy of retroperotoneal laparoscopic nephrectomy with autotransplantation in experienced hands.

Bedside Ultrasound in the Emergency Department to Detect Hydronephrosis for the Evaluation of Suspected Ureteric Colic

Background Renal colic is a common emergency department presentation. Hydronephrosis is indirect sign of urinary obstruction which may be due to obstructing ureteric calculus and can be detected easily by bedside ultrasound with minimal training. Objective To compare the accuracy of detection of hydronephrosis performed by the emergency physician with that of radiologist's in suspected renal colic cases. Method This was a prospective observational study performed over a period of 6 months. Patients >8 years with provisional diagnosis of renal colic with both the bedside ultrasound and the formal ultrasound performed were included. Presence of hydronephrosis in both ultrasounds and size and location of ureteric stone if present in formal ultrasound was recorded. The accuracy of the emergency physician detection of hydronephrosis was determined using the scan reported by the radiologists as the "gold standard" as computed tomography was unavailable. Statistical analysis was executed using SPSS 17.0. Result Among the 111 included patients, 56.7% had ureteric stone detected in formal ultrasound. The overall sensitivity, specificity, positive predictive value and negative predictive value of bedside ultrasound performed by emergency physician for detection of hydronephrosis with that of formal ultrasound performed by radiologist was 90.8%., 78.3%, 85.5% and 85.7% respectively. Bedside ultrasound and formal ultrasound both detected hydronephrosis more often in patients with larger stones and the difference was statistically significant (p=.000). Conclusion Bedside ultrasound can be potentially used as an important tool in detecting clinically significant hydronephrosis in emergency to evaluate suspected ureteric colic. Focused training in ultrasound could greatly improve the emergency management of these patients.

[A NOVEL SCORING SYSTEM: PREDICTING SEPTIC SHOCK AT DIAGNOSIS EASILY IN ACUTE COMPLICATED PYELONEPHRITIS PATIENTS]

(Objectives) Because acute complicated pyelonephritis can easily cause sepsis and concomitant shock status, it is a potentially lethal disease. However, the predictors for the severity of pyelonephritis is not well analyzed. In this study, we aimed at clarifying the clinical characteristic risk factors associated with septic shock in patients with acute complicated pyelonephritis. (Materials and methods) From May 2009 to March 2014, 267 patients with acute complicated pyelonephritis were treated at our institution. We investigated the characteristics of the patients associated with septic shock, and assessed risk factors in these patients. By using these risk factors, we established a novel scoring system to predict septic shock. (Results) 267 patients included 145 patients with ureteral calculi and 75 patients with stent-related pyelonephritis. Septic shock occurred in 35 patients (13%), and the mortality rate was 0.75%. Multivariate analysis revealed that (P): Performance Status ≥3 (p=0.0014), (U): Presence of Ureteral calculi (p=0.043), (S): Sex of female (p=0.023), and (H): the presence of Hydronephrosis (p=0.039) were independent risk factors for septic shock. P.U.S.H. scoring system (range 0-4), which consists of these 4 factors, were positively correlated with the rate of septic shock (score 0: 0%, 1: 5.3%, 2: 3.4%, 3: 25.0%, 4: 42.3%). Importantly, patients with 3-4 P.U.S.H. scores were statistically more likely to become septic shock than those with 0-2 score (p=0.00014). (Conclusions) These results suggest that P.U.S.H. scoring system using 4 clinical factors is useful to predict the status of septic shock in patients with acute complicated pyelonephritis.

Spontaneous rupture of common iliac artery associated with fibromuscular dysplasia presenting with colic pain suggestive of ureteral stone

We report a case of spontaneous rupture of the common iliac artery associated with fibromuscular dysplasia (FMD). A 21-year-old previously healthy male presented with acute onset of colic pain, suspected to be caused by a ureteral stone. Abdominal computed tomography and angiography revealed a retroperitoneal hematoma caused by rupture of the common iliac artery. In spite of an emergency operation initiated quickly, the patient died. A pathological examination demonstrated FMD of the common iliac artery. Although very rare, it is important to bear in mind that the possibility of retroperitoneal hemorrhage exists in patient with sudden lumbago.

Practical comparison of four nitinol stone baskets

BACKGROUND AND PURPOSE

The use of stone baskets for repositioning of stones or removal of fragment in conjunction with ureterorenoscopy has become widespread. We tested the performance of the ACMI Sur-Catch NT, Bard Dimension, Boston Scientific Zero-tip, and Cook N-Circle in a pig kidney model of flexible ureterorenoscopy.

MATERIALS AND METHODS

Opening characteristics of the basket were measured with mechanical calipers at 1-mm increments and compared with published reports to ensure the tested baskets were representative. Pig kidneys were placed in a basin and the ureters secured with a suture to a weight for stability. Flexible renoscopy was performed using a 16F flexible cystonephroscope. An 8-mm calculus was placed in the lower pole. Using each of four designs, the time necessary to grasp the stone, time to release the stone, and total time to move a stone from the lower-pole calix to the upper-pole were recorded. Total time experiments were repeated six times with each basket by three surgeons for a total of 18 attempts, and catch-and-release experiments were repeated six times by four surgeons for a total of 24 attempts per basket.

RESULTS

The Sur-Catch was significantly slower for catch and release (P < 0.001) and total time; P < 0.05) compared with all other baskets. There were no differences between the other baskets in either catch, release, or total times. There was no difference between surgeons (P < 0.0634) or between attempts one through six (P = 0.538).

CONCLUSIONS

Baskets with added complexity of the wire configurations (Sur-Catch) or a deflectable-wire mechanism (Dimension) offer no advantages and may slow capture and release of stones.

Blind puncture in comparison with fluoroscopic guidance in percutaneous nephrolithotomy: a randomized controlled trial

INTRODUCTION

Our aim was to evaluate blind puncture in percutaneous nephrolithotomy (PCNL) for decreasing the risk of radiation.

MATERIALS AND METHODS

One hundred candidates for PCNL were randomly assigned into 2 groups. Blind access was performed for the patients in group 1 and the standard access using fluoroscopy for those in group 2. In group 1, displacement of the targeted calyx in the prone position was estimated by fluoroscopy comparing to the image on intravenous urography. Puncture of the calyx was attempted 3 cm to 4 cm below the marked site of the targeted calyx with a 30 angle. If the access to the collecting system was felt and urine came out, the site of puncture would be controlled by fluoroscopy. If the access failed, we would repeat puncturing up to 5 times.

RESULTS

The mean time to access was 6.6 +/- 2.1 minutes and 5.5 +/- 1.7 minutes in groups 1 and 2, respectively (P = .008). The mean time of radiation exposure was 0.95 +/- 0.44 minutes in group 2. A successful puncture to the targeted calyx was achieved in 50% and 90% of the patients in groups 1 and 2, respectively (P < .001) and a successful calculus removal in 62% and 100% of the patients in groups 1 and 2 (P < .001).

CONCLUSION

Although about half of the patients benefited from blind access in our study, this technique can not be solely relied on, and fluoroscopy or ultrasonography should be available for prevention of complications.