Publications by authors named "Esteban Emiliani"

69 Publications

Worldwide practice patterns of percutaneous nephrolithotomy.

World J Urol 2022 Aug 1;40(8):2091-2098. Epub 2022 Jul 1.

EAU Young Academic Urologists (YAU) Urolithiasis and Endourology Working Group, Arnhem, The Netherlands.

Purpose: To evaluate the current practice of percutaneous nephrolithotomy (PCNL), conducting a worldwide survey among urologists with a special interest in endo-urology.

Methods: A 22-question survey was specifically developed by the European Association of Urology (EAU) young academic urologists (YAU) and uro-technology (ESUT) groups and globally distributed via SurveyMonkey to almost 2000 members of Endourology Society. The questionnaire included questions dedicated to the demographics and general practice of the participating urologists.

Results: In total, 441 responses (male/female ratio - 418/23) were received. A comparatively higher percentage of specialists (56.2%) practiced in academic institutions and had specific endo-urological fellowship training (56.7%). The classical prone PCNL remained the most practiced approach among the surveyed specialists, 47.7% stated to always do prone PCNLs, while 51.8% of respondents used multiple positioning options as required. The PCNL tract was mostly performed by urologists (84.3%) and fluoroscopic guidance was still predominantly used by 74.5% of respondents. The most practiced tract dilation method was balloon dilator used by 42% of respondents. Most of the surveyed urologists had ultrasonic, pneumatic or laser lithotripsy devices in their armamentarium. The use of some form of post-procedural drainage was reported in 85.1% of respondents, whereas tubeless PCNL remained a fairly uncommon practice.

Conclusion: The majority of urologists still use prone positioning, get their own access under fluoroscopy guidance and use a balloon for tract dilation. However, we also identified that when necessary, urologists will deviate from routine practice and change strategy, adopting other approaches for PCNL.
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http://dx.doi.org/10.1007/s00345-022-04067-3DOI Listing
August 2022

New Generation Pulse Modulation in Holmium:YAG Lasers: A Systematic Review of the Literature and Meta-Analysis.

J Clin Med 2022 Jun 4;11(11). Epub 2022 Jun 4.

Department of Urology, Fundació Puigvert IUNA, 08017 Barcelona, Spain.

(1) Background: New pulse modulation (PM) technologies in Holmium:YAG lasers are available for urinary stone treatment, but little is known about them. We aim to systematically evaluate the published evidence in terms of their lithotripsy performance. (2) Methods: A systematic electronic search was performed (MEDLINE, Scopus, and Cochrane databases). We included all relevant publications, including randomized controlled trials, non-randomized comparative and non-comparative studies, and in-vitro studies investigating Holmium:YAG lithotripsy performance employing any new PM. (3) Results: Initial search yielded 203 studies; 24 studies were included after selection: 15 in-vitro, 9 in-vivo. 10 In-vitro compared Moses with regular PM, 1 compared Quanta's, 1 Dornier MedTech's, 2 Moses with super Thulium Fiber Laser, and 1 compared Moses with Quanta PMs. Six out of seven comparative studies found a statistically significant difference in favor of new-generation PM technologies in terms of operative time and five out of six in fragmentation time; two studies evaluated retropulsion, both in favor of new-generation PM. There were no statistically significant differences regarding stone-free rate, lasing and operative time, and complications between Moses and regular PM when data were meta-analyzed. (4) Conclusions: Moses PM seems to have better lithotripsy performance than regular modes in in-vitro studies, but there are still some doubts about its in-vivo results. Little is known about the other PMs. Although some results favor Quanta PMs, further studies are needed.
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http://dx.doi.org/10.3390/jcm11113208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9181640PMC
June 2022

How Reliable Is Endoscopic Stone Recognition? A Comparison Between Visual Stone Identification and Formal Stone Analysis.

J Endourol 2022 Jul 13. Epub 2022 Jul 13.

Department of Urology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands.

To assess the diagnostic accuracy and intra-observer agreement of endoscopic stone recognition (ESR) compared with formal stone analysis. Stone analysis is a corner stone in the prevention of stone recurrence. Although X-ray diffraction (XRD) and infrared spectroscopy are the recommended techniques for reliable formal stone analysis, this is not always possible, and the process takes time and is costly. ESR could be an alternative, as it would give immediate information on stone composition. Fifteen endourologists predicted stone composition based on 100 videos from ureterorenoscopy. Diagnostic accuracy was evaluated by comparing the prediction from visual assessment with stone analysis by XRD. After 30 days, the videos were reviewed again in a random order to assess intra-observer agreement. The median diagnostic accuracy for calcium oxalate monohydrate was 54% in questionnaire 1 (Q1) and 59% in questionnaire 2 (Q2), whereas calcium oxalate dihydrate had a median diagnostic accuracy of 75% in Q1 and 50% in Q2. The diagnostic accuracy for calcium hydroxyphosphate was 10% in Q1 and 13% in Q2. The median diagnostic accuracy for calcium hydrogen phosphate dihydrate and calcium magnesium phosphate was 0% in both questionnaires. The median diagnostic accuracy for magnesium ammonium phosphate was 20% in Q1 and 40% in Q2. The median diagnostic accuracy for uric acid was 22% in both questionnaires. Finally, there was a diagnostic accuracy of 60% in Q1 and 80% in Q2 for cystine. The intra-observer agreement ranged between 45% and 72%. Diagnostic accuracy of ESR is limited and intra-observer agreement is below the threshold of acceptable agreement.
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http://dx.doi.org/10.1089/end.2022.0217DOI Listing
July 2022

3D Imaging Segmentation and 3D Rendering Process for a Precise Puncture Strategy During PCNL - a Pilot Study.

Front Surg 2022 3;9:891596. Epub 2022 May 3.

Laboratory for Biomedical Instrumentation and Technologies, Department of Signals and Systems, University of Belgrade, School of Electrical Engineering, Belgrade, Serbia.

Percutaneous nephrolithotomy (PCNL) is frequently used as the first-line treatment of large and complex stones. The key point for successful complex stone removal with minimal risk of complications is to establish the most appropriate access route. Understanding the three-dimensional (3D) relationship of kidney stones and renal collecting systems is crucial for planning and creating an optimal access route. By using a 3D volume segmentation tool a more accurate approach to the renal collecting system and stone treatment could be planned. The objective of this study was assessing the impact of 3D software in getting the desired access.
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http://dx.doi.org/10.3389/fsurg.2022.891596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9110964PMC
May 2022

Emergency upper urinary tract decompression: double-J stent or nephrostomy? A European YAU/ESUT/EULIS/BSIR survey among urologists and radiologists.

World J Urol 2022 Jul 14;40(7):1629-1636. Epub 2022 Mar 14.

Associate Specialist in Urology, University Hospital Southampton, Southampton, UK.

Purpose: To evaluate the decompression of the pelvicalyceal system between urologists and radiologists.

Methods: A survey was distributed to urologists and to radiologists comparing double-J stent (DJS), percutaneous nephrostomy (PN) and primary ureteroscopy (URS) for three clinical scenarios (1-febrile hydronephrosis; 2-obstruction and persistent pain; 3-obstruction and anuria) before and after reading literature The survey included perception on radiation dose, cost and quality of life (QoL).

Results: Response rate was 40% (366/915). 93% of radiologists believe that DJS offers a better QOL compared to 70.6% of urologists (p = 0.006). 28.4% of urologists consider PN to be more expensive compared to 8.9% of radiologists (p = 0.006). 75% of radiologists believe that radiation exposure is higher with DJS as opposed to 33.9% of urologists. There was not a difference in the decompression preference in the first scenario. After reading the literature, 28.6% of radiologists changed their opinion compared to 5.2% of urologists (p < 0.001). The change favored DJS. In the second scenario, responders preferred equally DJS and they did not change their opinion. In the third scenario, 41% of radiologists chose PN as opposed to 12.6% of urologists (p < 0.001). After reading the literature, 17.9% of radiologists changed their opinion compared to 17.9% of urologists (p < 0.001), in favor of DJS. Although the majority of urologists (63.4%) consistently perform primary URS, only 3, 37 and 21% preferred it for the first, second and third scenarios, respectively.

Conclusion: The decision on the type of drainage of a stone-obstructing hydronephrosis should be individualized.
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http://dx.doi.org/10.1007/s00345-022-03979-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8918906PMC
July 2022

Does ureteral access sheath have an impact on ureteral injury?

Urol Ann 2022 Jan-Mar;14(1):1-7. Epub 2022 Jan 20.

Department of Urology, University of Patras, Patras, Greece.

Objective: To present a well-organized review about ureteral access sheath impact on ureteral injury.

Materials And Methods: Systemic search on literature was done. Total of 3766 studies observed by two urologists and results were unified. A Prisma diagram was used for eliminating irrelevant studies and at the end of elimination process 28 studies were found eligible for this review.

Results: Not only clinical studies but also comparative experimental animal studies show that there is no significant data to claim that ureteral access sheath insertion causes more ureteral injury. Pre-stented patients were found to be at lower risk for ureteral injury. Risk of progression to ureteral injury seems to be low even if ureteral injury occurs with insertion of ureteral access sheath.

Conclusion: Summary of studies' results indicate that use of ureteral access sheath doesn't increase ureteral injury. This review may help understanding safety profile of ureteral access sheath on evidence-based level. There is not enough data to make a statement that ureteral access sheath prevents ureteral injury.
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http://dx.doi.org/10.4103/UA.UA_163_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8815358PMC
January 2022

Propensity score-matched analysis comparing retrograde intrarenal surgery with percutaneous nephrolithotomy in anomalous kidneys.

Minerva Urol Nephrol 2022 Feb 11. Epub 2022 Feb 11.

Ng Teng Fong General Hospital, NUHS, Singapore.

Background: Endourologic interventions for urolithiasis in patients with anomalous kidneys can be challenging, and comparisons between these interventions are not well studied. We aim to compare the safety, outcomes and complications of retrograde intrarenal surgery (RIRS) versus percutaneous nephrolithotomy (PCNL) in patients with urolithiasis in anomalous kidneys.

Methods: A propensity score-matched pair analysis (PSM) was performed on pooled patient data from 20 centers. 569 patients with anomalous kidneys (Horseshoe kidney(HSK), ectopic kidney, malrotated kidney) and urolithiasis who received either PCNL or RIRS as the primary modality of intervention from 2010 to 2020 were analyzed. Patients were matched based on calculated propensity scores by a regression model using age, sex, comorbidities, stone size, and renal anomaly type as co-variates. Multivariate logistic regression of factors (mode of treatment [PCNL or RIRS], comorbidities, stone size) and their effects on outcomes of stone-free rate (SFR), need to abandon surgery due to intraoperative difficulty, postoperative hematuria and sepsis and were analyzed when applicable.

Results: After PSM, there were a total of 127 pairs in each group. Overall, PCNL conferred a higher SFR compared to RIRS (OR=3.69, 95%-CI=1.91-7.46, p<0.001), particularly in HSK (OR=3.33, 95%-CI=1.22-9.99, p=0.023), and ectopic kidneys (OR=18.10, 95%-CI=3.62-147.63, p=0.002), with no significant difference in malrotated kidneys. There was no significant difference in post-operative sepsis observed. Surgery was abandoned more often in RIRS than PCNL (6.3% vs 0%, p=0.014). Although PSM provides a robust analysis due to baseline differences in the unmatched cohorts, this study was limited by an inevitable degree of selection bias.

Conclusions: While both modalities are safe and efficacious, PCNL yields better SFR than RIRS in patients with anomalous kidneys, with no difference in post-operative sepsis rates. Patients may benefit from personalized management best carried out in high volume endourology centers.
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http://dx.doi.org/10.23736/S2724-6051.22.04664-XDOI Listing
February 2022

The fight between PCNL, laparoscopic and robotic pyelolithotomy: do we have a winner? A systematic review and meta-analysis.

Minerva Urol Nephrol 2022 Apr 11;74(2):169-177. Epub 2022 Feb 11.

European Society of Residents in Urology - ESRU, Arnhem, the Netherlands.

Introduction: The aim of this systematic review and meta-analysis was to provide an updated comparison between the currently available minimally invasive approaches (PCNL, laparoscopic [LP] and robotic pyelolithotomy [RP]) for the management of large renal stones.

Evidence Acquisition: An electronic search of the current literature was conducted through the Medline and NCBI PubMed, Embase, Scopus and Cochrane Collaboration Central Register of Controlled Clinical Trials databases in March 2021. Studies about minimally-invasive treatment for kidney stones were considered. Inclusion criteria were: studies evaluating patients with large renal calculi (≥2 cm); the comparison of at least two of the three approaches (PCNL, LP, RP), and reporting data suitable for meta-analysis evaluation. Patients with concomitant management for ureteropelvic junction obstruction (UPJ-O) were excluded.

Evidence Synthesis: Overall, 17 reports were considered for qualitative and quantitative synthesis, for a total cohort of 1079 patients, of which 534 with PCNL, 525 treated with LP, and 20 with RP. Of those, 16 compared PCNL with LP, while only 1 study compared LP with RP. PCNL mean operative time was statistically significantly shorter than LP and RP while mean estimated blood loss was statistically significantly higher for PNCL. No statistically significant differences were recorded among the three surgical approaches. Finally, PCNL demonstrated slightly, albeit statistically significant lower stone free rate when compared with LP.

Conclusions: PCNL, LP and RP may be safely and efficiently used to manage large renal stones. All three procedures showed reasonably low rate of complications with a satisfactory stone clearance rate.
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http://dx.doi.org/10.23736/S2724-6051.21.04587-0DOI Listing
April 2022

International Alliance of Urolithiasis (IAU) guideline on percutaneous nephrolithotomy.

Minerva Urol Nephrol 2022 01 31. Epub 2022 Jan 31.

Department of Urology, Biruni University, Medical School, Istanbul, Turkey -

Introduction: The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and provide a clinical framework for surgeons peforming PCNLs.

Evidence Acquisition: These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between 01/01/1976 to 31/07/2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence.

Evidence Synthesis: 47 recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imagings, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imagings and stone-free status evaluation, complications.

Conclusions: The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists peforming PCNLs, therefore to ensure safety and efficiency in PCNLs.
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http://dx.doi.org/10.23736/S2724-6051.22.04752-8DOI Listing
January 2022

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones.

Eur Urol Focus 2021 Nov 23. Epub 2021 Nov 23.

Department of Urology, West China Hospital of Sichuan University, Chengdu, China.

Background: Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide.

Objective: To develop recommendations for RIRS on the basis of existing data and expert consensus.

Design, Setting, And Participants: A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions.

Outcome Measurements And Statistical Analysis: The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%.

Results And Limitations: The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed.

Conclusions: The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting.

Patient Summary: An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.
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http://dx.doi.org/10.1016/j.euf.2021.10.011DOI Listing
November 2021

Bilateral same session renal stone surgery tolerance and complications.

Urol Ann 2021 Oct-Dec;13(4):336-339. Epub 2021 Sep 2.

Division of Urology, Department of Surgery, Ministry of the National Guard - Health Affairs.

Introduction: The prevalence rate of upper urinary tract calculi in Saudi Arabia is one of the highest globally. Bilateral renal stone management is an option but is still controversial.

Methodology: The study was a retrospective study, including 31 patients with bilateral renal or ureteric stones who underwent bilateral same-session ureterorenoscopy (BSS-URS). The data collected included age, gender, body mass index (BMI), stone burden bilaterally, operative time bilaterally, hospital stay, stone location, type of anesthesia, stone history, renal anomaly as well as pre- and postoperative JJ stenting. In addition, data related to complications (ureteric injury, renal failure, urinary tract infection, pain requiring an emergency department visit within 1 week of the procedure), the stone-free rate (defined as £ 3 mm asymptomatic stone fragment identified with computed tomography Kidney, Ureter and Bladder 3 months after surgery was also collected. The data were collected from the electronic patient record system, entered in an Excel spreadsheet, and descriptive analysis was done.

Results: In total, 31 patients were included, with the majority (80.6%, = 25) male. The mean age was 41.6 years, the mean BMI 28.7 ± 5.59, the mean operative time for each renal unit 46.53 ± 25.69 min, and the mean hospital stay 17.87 ± 8.43 h. The majority (96.7%, = 30) received general anesthesia. Less than half (40.3%, = 25) of the renal units had stones in multiple calyces and the majority (90.3%, = 56) of the renal units were stone free at the 3-month follow-up. A small proportion (3.2%, = 2) of the renal units were polycystic. Prestenting was documented in 40.3% ( = 25) of the renal units and the majority (95.2%, = 59) were stented postoperatively.

Conclusion: BSS-URS is a safe and a highly effective management option for bilateral renal stones.
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http://dx.doi.org/10.4103/UA.UA_128_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8525472PMC
September 2021

Real-world Global Outcomes of Retrograde Intrarenal Surgery in Anomalous Kidneys: A High Volume International Multicenter Study.

Urology 2022 01 29;159:41-47. Epub 2021 Oct 29.

Department of Urology, Ng Teng Fong General Hospital, Jurong East, Singapore.

Objective: To analyze the trends and outcomes of retrograde intrarenal surgery for treatment of urolithiasis in anomalous kidneys in a large international multicenter series.

Materials And Methods: We designed a multicentric retrospective study. Nineteen high-volume centers worldwide were included. Pre-, peri- and postoperative data were collected, and a subgroup analysis was performed according to renal anomaly.

Results: We analyzed 414 procedures: 119 (28.7%) were horseshoe kidneys, 102 (24.6%) pelvic ectopic kidneys, 69 (16.7%) malrotated kidneys and 50 (12.1%) diverticular calculus. The average size (SD) of the stone was 13.9 (±6) millimeters and 193 (46.6%) patients had a pre-operative stent. In 249 cases (60.1%) a disposable scope was used. A UAS (ureteral access sheath) was used in 373 (90%) patients. A Holmium laser was used in 391 (94.4%) patients. The average (SD) operating time was 65.3 (±24.2) minutes. Hematuria, caliceal perforation and difficulty in stone localisation were mostly seen in diverticular stones and difficulty in UAS placement and lithotripsy in the cases of renal malrotation. The overall complication rate was 12%. Global stone-free rate was 79.2%. Residual fragments (RF) were significantly lesser in the pre-stented group (P <.05). Diverticular calculi was the group with more RF and needed ancillary procedures (P <.05).

Conclusion: Retrograde intrarenal surgery in patients with anomalous kidneys is safe and effective with a high single-stage stone-free rate and low complication rate. There is a trend toward using smaller and disposable scopes and smaller UAS. Diverticular stones can still be challenging with higher rates of intraoperative hematuria, caliceal perforation and RF.
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http://dx.doi.org/10.1016/j.urology.2021.10.003DOI Listing
January 2022

A Machine Learning Predictive Model for Post-Ureteroscopy Urosepsis Needing Intensive Care Unit Admission: A Case-Control YAU Endourology Study from Nine European Centres.

J Clin Med 2021 Aug 29;10(17). Epub 2021 Aug 29.

Department of Urology, University Hospital Southampton, Southampton SO16 6YD, UK.

Introduction: With the rise in the use of ureteroscopy and laser stone lithotripsy (URSL), a proportionate increase in the risk of post-procedural urosepsis has also been observed. The aims of our paper were to analyse the predictors for severe urosepsis using a machine learning model (ML) in patients that needed intensive care unit (ICU) admission and to make comparisons with a matched cohort.

Methods: A retrospective study was conducted across nine high-volume endourology European centres for all patients who underwent URSL and subsequently needed ICU admission for urosepsis (Group A). This was matched by patients with URSL without urosepsis (Group B). Statistical analysis was performed with 'R statistical software' using the 'randomforests' package. The data were segregated at random into a 70% training set and a 30% test set using the 'sample' command. A random forests ML model was then built with = 300 trees, with the test set used for internal validation. Diagnostic accuracy statistics were generated using the 'caret' package.

Results: A total of 114 patients were included (57 in each group) with a mean age of 60 ± 16 years and a male:female ratio of 1:1.19. The ML model correctly predicted risk of sepsis in 14/17 (82%) cases (Group A) and predicted those without urosepsis for 12/15 (80%) controls (Group B), whilst overall it also discriminated between the two groups predicting both those with and without sepsis. Our model accuracy was 81.3% (95%, CI: 63.7-92.8%), sensitivity = 0.80, specificity = 0.82 and area under the curve = 0.89. Predictive values most commonly accounting for nodal points in the trees were a large proximal stone location, long stent time, large stone size and long operative time.

Conclusion: Urosepsis after endourological procedures remains one of the main reasons for ICU admission. Risk factors for urosepsis are reasonably accurately predicted by our innovative ML model. Focusing on these risk factors can allow one to create predictive strategies to minimise post-operative morbidity.
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http://dx.doi.org/10.3390/jcm10173888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432042PMC
August 2021

Impact of the adherence to medical treatment on the main urinary metabolic disorders in patients with kidney stones.

Asian J Urol 2021 Jul 6;8(3):275-279. Epub 2020 Aug 6.

Urology Department, Hospital Regional de Alta Especialidad del Bajío, Blvd. Milenio #130, Col. San Carlos la Roncha, León, Guanajuato, Mexico.

Objective: To assess the effect of the adherence to medical treatment on urinary parameters in the 24-h metabolic study of patients with kidney stones.

Methods: A retrospective, longitudinal, descriptive, and observational study was carried out by reviewing the hospital electronic medical record from 2014 to 2018. The adherence to drug treatment was measured 6 months after its initiation, and the numerical values of the metabolic studies were compared. Wilcoxon tests were performed to compare the difference before and after treatment.

Results: Ninety patients were evaluated, with 73.3% of adherence. The 180-day overall adherence rate was 61.2% in patients treated with a single drug and 85.4% in patients treated with multiple drugs. There is a statistically significant increase in citrate levels in patients with good adherence in comparison with non-adherent patients (=0.031 =0.528).

Conclusions: Medical treatment and dietary measures in patients with kidney stones have an initial impact at 6 months on the values of the main urinary metabolic alterations that predispose to calculi formation; the most significant is seen in those patients with adherence to medical treatment for hypocitraturia.
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http://dx.doi.org/10.1016/j.ajur.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356059PMC
July 2021

Role and Importance of Ergonomics in Retrograde Intrarenal Surgery: Outcomes of a Narrative Review.

J Endourol 2022 01;36(1):1-12

Division of Urology, Ng Teng Fong General Hospital, National University Health System, Singapore, Singapore.

With recent technological advancement, new and improved endoscopic instruments and laser devices have catapulted flexible ureteroscopy to the forefront, hence making retrograde intrarenal surgery (RIRS) a popular choice for the management of renal stones. However, RIRS has also resulted in an increasing number of work-related musculoskeletal disorders, which can have a detrimental impact on surgeons' physical health and operative lifespan. The aim of our review is to examine the impact and feasibility of ergonomic adjustments and outline future directions and recommendations to improve the awareness of and reduce the prevalence of musculoskeletal injuries among urologists. This study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A thorough literature review was conducted of several databases using the following keywords and Medical Subject Headings (MeSH) terms to generate a search strategy: nephrolithiasis, kidney calculus, renal calculus, staghorn calculus, ergonomics, position, fatigue, comfort, tire, physical strain, visual strain, muscle, ureteroscopy, RIRS, laser, and lithotripsy. Studies were chosen for inclusion by reviewers independently, and the data were consolidated for analysis. A total of 1446 articles were identified on initial literature search; 23 were included in the final analysis. The impact of various ergonomic modifications on operative outcomes, surgeons, surgical equipment, and patients, was analyzed. In addition, we summarized all the improvements that resulted in better ergonomics in RIRS. Ergonomics in RIRS is poorly understood and there are currently no formal guidelines for this aspect. While modern endourology armamentarium seems to help with procedural ergonomics, more needs to be done to enhance surgeon comfort, protect surgeon longevity, and prioritize the health and safety of endourologists.
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http://dx.doi.org/10.1089/end.2021.0326DOI Listing
January 2022

Global Variations in the Mineral Content of Bottled Still and Sparkling Water and a Description of the Possible Impact on Nephrological and Urological Diseases.

J Clin Med 2021 Jun 27;10(13). Epub 2021 Jun 27.

Department of Urology, University Hospital Southampton NHS Trust, Southampton SO16 6YD, UK.

Kidney stone disease (KSD) is a complex disease. Besides the high risk of recurrence, its association with systemic disorders contributes to the burden of disease. Sufficient water intake is crucial for prevention of KSD, however, the mineral content of water might influence stone formation, bone health and cardiovascular (CVD) risk. This study aims to analyse the variations in mineral content of bottled drinking water worldwide to evaluate the differences and describes the possible impact on nephrological and urological diseases. The information regarding mineral composition (mg/L) on calcium, bicarbonate, magnesium, sodium and sulphates was read from the ingredients label on water bottles by visiting the supermarket or consulting the online shop. The bottled waters in two main supermarkets in 21 countries were included. The evaluation shows that on a global level the mineral composition of bottled drinkable water varies enormously. Median bicarbonate levels varied by factors of 12.6 and 57.3 for still and sparkling water, respectively. Median calcium levels varied by factors of 18.7 and 7.4 for still and sparkling water, respectively. As the mineral content of bottled drinking water varies enormously worldwide and mineral intake through water might influence stone formation, bone health and CVD risk, urologists and nephrologists should counsel their patients on an individual level regarding water intake.
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http://dx.doi.org/10.3390/jcm10132807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267898PMC
June 2021

Variations in the mineral content of bottled 'carbonated or sparkling' water across Europe: a comparison of 126 brands across 10 countries.

Cent European J Urol 2021 19;74(1):71-75. Epub 2021 Feb 19.

University Hospital Southampton NHS Trust, Department of Urology, Southampton, United Kingdom.

Introduction: Kidney stone disease is a common disease with high recurrence rates. Sufficient intake of water is the cornerstone in primary prevention of stone disease. However, the mineral composition of water can affect urinary minerals and influence stone formation. The aim of this study is to assess the variation in the mineral composition of bottled sparkling or carbonated drinking water across Europe.

Material And Methods: The two largest supermarket chains in each participating country were visited to obtain data on mineral composition regarding bicarbonate, calcium, magnesium, potassium, sodium and sulphates of sparkling or carbonated waters by reading the ingredient labels on the bottles supplied by the manufacturers. Alternatively, the web-shops of these supermarkets were consulted.

Results: In total, 126 sparkling water brands across ten European countries were analysed regarding mineral composition. The median concentrations per mineral varied greatly. The greatest variation in median mineral content was found for sodium and sulphates with levels ranging from 3.1 mg/l to 63.0 mg/l and 6.0 mg/l to 263.0 mg/l respectively. A wide distribution of calcium content was found in Switzerland, with calcium levels reaching up to 581.6 mg/l.

Conclusions: This study confirms that the mineral composition of sparkling or carbonated water varies greatly across Europe. Patients with kidney stone disease should be aware that the mineral content of water may influence stone formation and be mindful of the great variation that exists between different water brands. Mineral water can be a source of potential promotors or inhibitors of stone formation and patients and urologists need to be mindful of this.
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http://dx.doi.org/10.5173/ceju.2021.0331.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097654PMC
February 2021

A Novel Visual Grading for Ureteral Encrusted Stent Classification to Help Decide the Endourologic Treatment.

J Endourol 2021 Sep 13;35(9):1314-1319. Epub 2021 Aug 13.

Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona Spain.

The aim of the study is to propose a visual classification for encrusted stents (ESs) to help choose the appropriate endourologic treatment. A multicenter, retrospective, and descriptive study was performed. A total of 140 patients with encrusted Double-J stents were enrolled from 5 different institutions. The novel visual grading for ureteral encrusted stent (V-GUES) classification system ranges from A to D, increasing with severity of encrustation. ESs could be removed with a single intervention in 112 patients (86.8%). Type A and B ESs could be removed in all patients (100% success). Type D stents had minor retrieval and stone-free rates ( = 0.006 and  < 0.0001, respectively). Flexible ureteroscopy had a low success rate (77.7%) for type C stents (odds ratio [OR]: 0.21). Combined access had a 100% success rate for retrieval of type C ESs and a 92.9% success rate for type D ESs (OR: 9.18). Type D stents were associated with patients requiring more than one session to retrieve the stent (OR: 0.11) and stones (OR: 0.21). The V-GUES system is associated with treatment success rates of ES retrieval and stone-free status. It is also associated with the complication rate and the number of sessions needed for patients to be stent and stone free. The V-GUES classification could help counsel patients about the best treatment options and their outcomes. Further prospective studies will be needed to provide external validation.
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http://dx.doi.org/10.1089/end.2020.1225DOI Listing
September 2021

Oral Acidification with l-Methionine as a Noninvasive Treatment for Encrusted Uropathy.

J Endourol Case Rep 2020 17;6(3):143-146. Epub 2020 Sep 17.

Department of Urology, Fundació Puigvert, Barcelona, Spain.

Encrusted uropathy (EU) is a rare disease caused by urea-splitting bacteria, most commonly , whose incidence is increasing. Standard treatment is based on pathogen-directed antibiotic therapy, urinary diversion, bladder instillations, and surgical resection of urinary calcifications. We present the case of a 60-year-old man with symptomatic bilateral encrusted pyelitis and cystitis with acute renal failure. We initially treated the patient with antibiotic therapy, urinary diversion, and oral acidification with acetohydroxamic acid, achieving negative urinary cultures. Because of the persistence of encrusted pyelitis, the patient was discharged on oral l-methionine 500 mg bid and 12 months later the encrustations had almost disappeared. Finally, we performed right retrograde intrarenal surgery to remove a persistent small calcification. Oral urinary acidification with l-methionine is a valid treatment for urinary encrustations in EU, with no complications reported. Complete resolution of the calcifications may be achieved without the need for invasive processes and unnecessary manipulation of the urinary system.
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http://dx.doi.org/10.1089/cren.2019.0164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7580645PMC
September 2020

Prone versus supine percutaneous nephrolithotomy: a systematic review and meta-analysis of current literature.

Minerva Urol Nephrol 2021 02 5;73(1):50-58. Epub 2020 Oct 5.

Department of Urology, Campus Bio-Medico University, Rome, Italy.

Introduction: Percutaneous nephrolithotomy (PNL) can be performed either in prone or supine position. This study aimed at gathering together randomized controlled trials (RCTs) comparing efficacy and safety between prone and supine PNL.

Evidence Acquisition: Systematic review of literature was conducted using the Scopus, Medline and Web of Science databases. Study selection, data extraction and quality assessment were independently assessed by two authors. Meta-analysis was performed with Review Manager 5.3. Sensitivity analyses were performed to exclude studies with high risk of bias.

Evidence Synthesis: Pooled data from 12 studies including 1290 patients were available for analysis. Only one study was found to have overall low risk of bias. Significantly shorter operative time was found in favor of supine PNL (mean difference 13 minutes, 95% confidence interval [CI]: 3.4-22.7; P<0.01). Stone-free rate (SFR)≥14 days after surgery was significantly higher in prone PNL (odds ratio [OR]=2.15, 95% CI: 1.07-4.34; P=0.03). Significantly higher fever rate was found in prone PNL (OR=1.60, 95% CI: 1.03-2.47; P=0.04). Overall SFR, hospital stay length, complications rate, transfusions rate and blood loss, as well as non-lower calyx puncture rate, puncture attempts and tubeless intervention rate did not differ between prone and supine PNL (P>0.05).

Conclusions: Efficacy of PNL seems balanced between prone and supine position, with comparable overall SFR and shorter operative time in favor of supine PNL. Safety of PNL appears in favor of supine PNL, with lower fever rate. Because of study heterogeneity and possible risks of outcome bias, results from this study should be interpreted with caution. Altogether, both prone and supine PNL account for appropriate therapy options.
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http://dx.doi.org/10.23736/S2724-6051.20.03960-0DOI Listing
February 2021

Phytotherapy and Herbal Medicines for Kidney Stones.

Curr Drug Targets 2021 ;22(1):22-30

Department of Urology, Fundación puigvert. Universidad Autónoma de Barcelona, Barcelona, Spain.

Background: Kidney stones are one of the longest known and most common diseases in the urinary tract, with a prevalence that ranges from 1% to 20%. Many phytotherapeutic and herbal medicines have been described for the treatment and prevention of kidney stones.

Objective: The aim of this study was to perform a comprehensive review of publications on various phytotherapeutic and herbal medicines, including both clinical and animal studies.

Results: Phytotherapy may influence the risk of recurrence of calcium oxalate and uric acid stones. The most solid evidence relates to Phyllanthus niruri, one of the most studied phytotherapeutics; findings suggest that it interferes with calcium oxalate crystallization, reduces hyperoxaluria and hyperuricosuria, and increases the efficacy of shock wave lithotripsy due to reduced crystallization, without significant adverse effects. Theobromine has been shown to reduce the crystallization of uric acid in patients and appears to be a promising supplement to treat such stones.

Conclusion: Many phytotherapeutic and herbal agents have been studied for the treatment of urolithiasis, most of them only in a small number of patients or in animal models. Further randomized clinical trials are needed to evaluate the effects of these agents on kidney stones.
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http://dx.doi.org/10.2174/1389450121666200929115555DOI Listing
November 2021

High-power, High-frequency Ho:YAG Lasers Are Essential for Retrograde Intrarenal Surgery.

Eur Urol Focus 2021 01 15;7(1):3-4. Epub 2020 Sep 15.

Department of Urology, Fundación Puigvert, Autonomous University of Barcelona, Barcelona, Spain.

Advances in Ho:YAG technology have led to the appearance of high-power and high-pulse-frequency lasers that allow a wider range of options and greater versatility when choosing settings to achieve precise and effective lithotripsy.
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http://dx.doi.org/10.1016/j.euf.2020.08.008DOI Listing
January 2021

The Impact of Ureteroscopy following Computerized Tomography Urography in the Management of Upper Tract Urothelial Carcinoma.

J Urol 2021 02 16;205(2):392-399. Epub 2020 Sep 16.

Fundació Puigvert, Department of Urology, Autonomous University of Barcelona, Barcelona, Spain.

Purpose: We report the reliability of computerized tomography urography and ureteroscopy in the diagnosis and management of upper tract urothelial carcinoma.

Materials And Methods: From 2015 to November 2018 we prospectively collected and retrospectively analyzed 244 cases of ureteroscopy with available preoperative computerized tomography urography. Computerized tomography urography was categorized as positive, suspicious, unlikely and negative. Correspondence between imaging, ureteroscopy and histology was analyzed. The therapeutic indication, based on 2020 EAU Guidelines and patient clinical data, was recorded before and after ureteroscopy. Cohen's Kappa was used for agreement analysis. Logistic regression was used for prediction of positive ureteroscopy.

Results: Ureteroscopy was positive for upper tract urothelial carcinoma in 107/115 (93%), 48/77 (62.3%), 15/27 (55.6%) and 12/25 (48%) cases with positive, suspicious, unlikely and negative computerized tomography urography, respectively. On cytohistology the result was confirmed in 164/182 (90.1%) cases. The positive predictive value of a filling defect, stenosis, thickening and hydronephrosis on computerized tomography urography was 87.7% (121/138 cases), 65.6% (21/32), 69.6% (64/92) and 79.7% (59/74), respectively. On multivariate analysis a filling defect (95% CI 2.76-11.5, OR 5.63, p <0.0001) or hydronephrosis (1.04-6.18, OR 2.52, p=0.04) was associated with ureteroscopy outcome. Among cases with positive computerized tomography urography and ureteroscopy, the lesions differed in dimensions (20/107), number (14/107) and site (11/107), for a total of 45/107 (42.1%) cases. The indication of elective treatment changed after ureteroscopy in 37/76 (48.1%) cases (Kappa=0.31), as 17/28 (60.7%), 11/20 (55%) and 11/28 (39.2%) indications were confirmed for endoscopic management, ureterectomy and nephroureterectomy, respectively.

Conclusions: The complementary use of computerized tomography urography and ureteroscopy in the diagnostic workup of upper tract urothelial carcinoma should be evaluated.
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http://dx.doi.org/10.1097/JU.0000000000001370DOI Listing
February 2021

Variations in the Mineral Content of Bottled "Still" Water Across Europe: Comparison of 182 Brands Across 10 Countries.

J Endourol 2021 02 11;35(2):206-214. Epub 2020 Sep 11.

Department of Urology, University Hospital Southampton NHS Trust, Southampton, United Kingdom.

Kidney stone disease (KSD) is a highly prevalent disease worldwide. As water intake and its mineral content influence stone formation and recurrence, patients and physicians must be aware of the mineral content of drinkable water. We analyzed commercial bottled still water within Europe to assess the variation in its mineral composition across different manufacturers and countries. Data on the mineral composition of bottled still water regarding bicarbonate, calcium, magnesium, potassium, sodium, and sulfate concentration (mg/L) were collected from ten European countries. To collect the data, the two main supermarket chains in each participating country were either visited to check for the ingredient label on bottles or the online shop was consulted through the website of the supermarket in question. Descriptive statistics such as simple boxplots were used to illustrate the variation in mineral content. One hundred eighty-two different commercial water brands were analyzed. Up to a fivefold variation in average concentrations per mineral between countries was observed. For calcium, a wide distribution was found in France and Switzerland compared with other countries with calcium levels ranging from 10.5 to 565 mg/L and 8.4 to 579 mg/L, respectively. By consuming 2 L of water with such high calcium levels, the daily reference intake for calcium is already achieved. The mineral content of bottled still water across Europe varies greatly. For patients with KSD it is important to be aware of the mineral content of the water they drink, as it might influence stone recurrence rates and necessitate alterations of their diet.
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http://dx.doi.org/10.1089/end.2020.0677DOI Listing
February 2021

Exploratory analysis on the usage of Pi-score algorithm over endoscopic stone treatment step 1 protocol.

Minerva Urol Nephrol 2021 10 4;73(5):662-667. Epub 2020 Aug 4.

Department of Urology, University of Southampton, Southampton, UK.

Background: The Performance Improvement score (Pi-score) has been proven to be reliable to measure performance improvement during E-BLUS hands-on training sessions. Our study is aimed to adapt and test the score to EST s1 (Endoscopic Stone Treatment step 1) protocol, in consideration of its worldwide adoption for practical training.

Methods: The Pi-score algorithm considers time measurement and number of errors from two different repetitions (first and fifth) of the same training task and compares them to the relative task goals, to produce an objective score. Data were obtained from the first edition of 'ART in Flexible Course', during four courses in Barcelona and Milan. Collected data were independently analyzed by the experts for Pi assessment. Their scores were compared for inter-rater reliability. The average scores from all tutors were then compared to the PI-score provided by our algorithm for each participant, in order to verify their statistical correlation. Kappa statistics were used for comparison analysis.

Results: Sixteen hands-on training expert tutors and 47 3-year residents in Urology were involved. Concordance found between the 16 proctors' scores was the following: Task 1=0.30 ("fair"); Task 2=0.18 ("slight"); Task 3=0.10 ("slight"); Task 4=0.20, ("slight"). Concordance between Pi-score results and proctor average scores per-participant was the following: Task 1=0.74 ("substantial"); Task 2=0.71 ("substantial"); Task 3=0.46 ("moderate"); Task 4=0.49 ("moderate").

Conclusions: Our exploratory study demonstrates that Pi-score can be effectively adapted to EST s1. Our algorithm successfully provided an objective score that equals the average performance improvement scores assigned by of a cohort of experts, in relation to a small amount of training attempts.
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http://dx.doi.org/10.23736/S2724-6051.20.03747-9DOI Listing
October 2021

Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a multicenter, placebo controlled, double blind, randomized clinical trial.

BMC Urol 2020 Jun 5;20(1):65. Epub 2020 Jun 5.

Devicare S.L., Cerdanyola del Vallès, Spain.

Background: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks.

Methods: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 - none; 3 - global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events.

Results: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the placebo group and 18.91 (102.27) in the intervention group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups.

Conclusions: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation.

Trial Registration: This trial was registered at www.clinicaltrials.gov under the name "Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent" with date 2nd November 2017, code NCT03343275, and URL.
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http://dx.doi.org/10.1186/s12894-020-00633-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275439PMC
June 2020

Percutaneous Nephrolithotomy in Horseshoe Kidneys: Results of a Multicentric Study.

J Endourol 2021 07 22;35(7):979-984. Epub 2020 Jun 22.

Glickman Urological and Kidney Institute, Cleveland, Ohio, USA.

To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of  < 0.05 were considered significant. We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 27.7,  = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% 2.6% ( = 0.99), 16.9% 18.4% ( = 0.99), and 52.5% 69.2% ( = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 100 minutes,  = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group ( < 0.001). The prone group had significantly more Clavien 2 complications than the supine ( = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.
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http://dx.doi.org/10.1089/end.2020.0128DOI Listing
July 2021

Systematic Review and Meta-Analysis Comparing Percutaneous Nephrolithotomy, Retrograde Intrarenal Surgery and Shock Wave Lithotripsy for Lower Pole Renal Stones Less Than 2 cm in Maximum Diameter.

J Urol 2020 Sep 9;204(3):427-433. Epub 2020 Mar 9.

Young Academic Urologist.

Purpose: The aim of the current systematic review and meta-analysis is to provide an answer on which is the most appropriate approach for the management of the lower pole stones with a maximal dimension of 2 cm or less.

Materials And Methods: A systematic review was conducted on PubMed®, SCOPUS®, Cochrane and EMBASE®. The PRISMA guidelines and the recommendations of the EAU Guidelines office were followed. Retrograde intrarenal surgery, shock wave lithotripsy and percutaneous nephrolithotomy were considered for comparison. The primary end point was the stone-free rate.

Results: A total of 15 randomized controlled trials were eligible. Percutaneous nephrolithotripsy and retrograde intrarenal surgery have higher stone-free rates in comparison to shock wave lithotripsy and require fewer re-treatment sessions. Operative time and complications seem to favor shock wave lithotripsy in comparison to percutaneous nephrolithotripsy, but this takes place at the expense of multiple shock wave lithotripsy sessions. Retrograde intrarenal surgery seems to be the most efficient approach for the management of stones up to 1 cm in the lower pole.

Conclusions: The pooled analysis of the eligible studies showed that the management of lower pole stones should probably be percutaneous nephrolithotripsy or retrograde intrarenal surgery to achieve stone-free status over a short period and minimal number of sessions. For stones smaller than 10 mm, retrograde intrarenal surgery is more efficient in comparison to shock wave lithotripsy. The decision between the 2 approaches (percutaneous nephrolithotripsy or retrograde intrarenal surgery) should be individual, based on the anatomical parameters, the comorbidity and the preferences of each patient.
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http://dx.doi.org/10.1097/JU.0000000000001013DOI Listing
September 2020
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