Consensus of multiple national guidelines: agreed strategies for initial stone management during COVID-19

PURPOSE

To review the existing available information regarding urolithiasis management and the impact of COVID-19 on this, and propose recommendations for management of emergency urolithiasis presentations in the COVID-19 era.

METHODS

Review of published guidelines produced by Urological Governing Bodies, followed by the literature review regarding urolithiasis management during the COVID-19 pandemic.

RESULTS

Consistent recommendations across guidelines and literature were that urolithiasis with concurrent sepsis or renal failure remains a urological emergency warranting urgent intervention within the pandemic environment. Ureteric stenting and percutaneous nephrostomy are considered equivalent for decompression in this setting, with both ideally to be performed under local anaesthesia where possible to spare ventilators and reduce aerosol-generating procedures. Greater utilization of medical expulsive therapy and dissolution chemolysis may occur during the pandemic, and longer indwelling stent times may be accepted while definite stone clearance is deferred.

CONCLUSIONS

Urolithiasis will continue to be a source of emergency presentations requiring urgent intervention during the COVID-19 pandemic. However, it is possible to limit these interventions to decompression of the collecting system in the setting of concurrent obstruction or infection, performed under local anaesthesia to limit use of resources and minimise aerosol-generating procedures, with deferral of definitive management.

A Usability Comparison of Laser Suction Handpieces for Percutaneous Nephrolithotomy

INTRODUCTION

The holmium laser has revolutionized the practice of minimally invasive endoscopy for kidney stones. Recently, a novel, rigid handpiece for use in percutaneous nephrolithotomy (PCNL) that couples the holmium laser with suction has been developed. To date, limited data exist regarding the usability and ergonomics of such treatment systems. We thus sought to compare surgeon-rated usability with three different suction laser handpieces in a porcine model.

MATERIALS AND METHODS

We performed bilateral reverse PCNL on four female domestic farm pigs. After induction of general anesthesia, percutaneous access was obtained into each kidney by using biplanar fluoroscopy and 8 mm stones (plaster of Paris) were inserted into the calix or renal pelvis for treatment. Four surgeons tested the LASER Suction Tube (Karl Storz^®, Germany), LithAssist™ (Cook^® Medical), and Suction Handpiece (HP) (Lumenis^®, Israel) by using a combination of fragmentation (5 Joules/20 Hertz) and dusting (0.8 Joules/80 Hertz) settings on the Lumenis pulse 120 H laser. The primary outcome assessed was the ease of use of the three devices as measured by a surgeon questionnaire.

RESULTS

A total of 15 stones were treated in 8 renal units. The mean time required for stone fragmentation was 8 min. The mean handling and suction efficiency scores were similar between devices. The Suction HP offered the best laser fiber visibility during lithotripsy.

CONCLUSION

Suction laser handpieces offer an option to treat renal stones via PCNL, with limited differences noted in most surgeon ratings between devices.

Percutaneous Nephrolithotomy in the Superobese: A Comparison of Outcomes Based on Body Mass Index

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is considered the gold standard for treatment of large renal calculi. Although several investigators have examined the feasibility and outcomes associated with PCNL in obese patients, these studies have been limited by small sample size, lack of a comparator group, or few patients at body mass index (BMI) extremes. We thus compared outcomes of superobese (BMI >50) patients undergoing PCNL vs both an "overweight" and "ideal" cohort.

METHODS

We used a prospectively maintained database to identify ideal (BMI 18.5-25), overweight (BMI 25.1-49.9), and superobese (BMI ≥50) patients who underwent PCNL. Our primary objective was to compare surgical outcomes between groups measured by the percent of patients who required secondary PCNL. We then compared complication rates, need for transfusion, and length of stay (LOS) using chi-square testing and ANOVA where appropriate.

RESULTS

A total of 1152 patients were identified of which 254 were classified as ideal, 840 as overweight, and 58 as superobese. The overweight cohort had a higher mean age and greater proportion of males, whereas staghorn stones were more common in the superobese group. Comorbid conditions were more commonly observed in the superobese cohort. Otherwise, the groups were similar. Surgical outcomes were comparable with 47.2%, 42.0%, and 38.0% of ideal, overweight, and superobese patients requiring secondary PCNL (p = 0.25) with no difference in complication rates, need for transfusion, or LOS.

CONCLUSION

PCNL can be effectively and safely performed in superobese patients with no difference in surgical outcomes or complications when compared to ideal or overweight patient cohorts.

Transgluteal CT-Guided Percutaneous Renal Access for Percutaneous Nephrolithotomy in a Pelvic Horseshoe Kidney

CT-guided percutaneous renal access has been described as a safe and effective access technique in patients with complex anatomy, including ectopic kidney, retrorenal colon, spinal dysraphism, hepatomegaly, and splenomegaly. In comparison to conventional intraoperative fluoroscopic-guided access, CT imaging allows for delineation of surrounding structures that are at risk for injury during percutaneous access. However, previous reports indicate that pelvic kidneys might be inaccessible percutaneously without laparoscopic assistance. Herein, we present a novel transgluteal route to renal access for percutaneous nephrolithotomy (PCNL) in a patient with a pelvic horseshoe kidney and severe spinal deformity.

Coping with caregiving: supporting the informal caregiver

Community health nurses often work side by side with informal caregivers. Professional caregivers can reduce their own stress and that of their patients by helping to reduce the stress of the informal caregivers, who provide a great deal of support and medical care to their loved ones.