The use of internal stents in chronic ureteral obstruction.

PURPOSE: Despite the lack of a well delineated definition, chronic ureteral obstruction imposes significant quality of life loss, increased pathological morbidity and risk of mortality as well as substantial economic burden. Ureteral stenting serves as an important therapeutic option to alleviate obstruction. Thus, we assessed the recently published literature on chronic ureteral obstruction; treatment options; types, benefits and shortcomings of current ureteral stents; as well as outcomes and complications of chronic ureteral stenting, with the goal of providing concise management guidelines. MATERIALS AND METHODS: A systemic literature review was performed on Embase™, PubMed®, Cochrane Controlled Trials Register and Google Scholar™ on ureteral obstruction and internal ureteral stents. Relevant reviews, original research articles and their cited references were examined, and a synopsis of original data was generated on a clinically oriented basis. RESULTS: Chronic ureteral obstruction can be classified into compression that is either intrinsic or extrinsic to the ureteral wall, or obstruction that is of a benign or malignant origin. Patients with malignant ureteral obstruction generally have a poor prognosis and are often difficult to treat. The aim of stenting is to adequately drain the upper urinary tracts while minimizing hospitalization and the negative impact on quality of life. Facing the challenge of chronic ureteral obstruction, novel stents with new compositions, materials, coatings and designs have been developed. Metallic stents are emerging as efficacious and financially viable alternatives. Early stent related complications include iatrogenic injury, stent migration or patient discomfort, while late complications include infection, difficulties with stent exchange, hardware malfunction, infection and stent encrustation. CONCLUSIONS: Stenting in chronic ureteral obstruction is a complex and challenging problem. Much work is being done in this area and many options are being explored.

Classification and standardized reporting of percutaneous nephrolithotomy (PCNL): International Alliance of Urolithiasis (IAU) Consensus Statements.

BACKGROUND: The aim of this study was to reach a consensus in the classification and standardized reporting for the different types of PCNLs. METHODS: The RAND/UCLA appropriateness methodology was used to reach a consensus. Thirty-two statements were formulated reviewing the literature on guidelines and consensus on PCNLs, and included procedure specific details, outcome measurements and a classification for PCNLs. Experts were invited to two rounds of input, the first enabled independent modifications of the proposed statements and provided the option to add statements. The second round facilitated scoring of all statements. Each statement was discussed in the third round to decide which statements to include. Any suggestion or disagreement was debated and discussed to reach a consensual agreement. RESULTS: Twenty-five recommendations were identified to provide standardized reporting of procedure and outcomes. Consensual scoring above 80% were strongly agreed upon by the panel. The top treatment related outcomes were size of sheath used (99.1%) and position for PCNL (93.5%). The highest ranked Outcome Measures included definition of postoperative hospital length of stay (94.4%) and estimated blood loss (93.5%). CONCLUSIONS: The consensus statements will be useful to clarify operative technique, in the design of clinical trials and standardized reporting, and presentation of results to compare outcomes of different types of PCNLs.

Percutaneous nephrolithotomy made easier: a practical guide, tips and tricks.

Percutaneous nephrolithotomy (PCNL) plays an integral role in managing large renal stones. Establishing percutaneous renal access is the most crucial step in the procedure and requires a thorough understanding of renal, retroperitoneal and thoracic anatomy to minimize the risk of complications. Moreover, access to fluoroscopy and the proper equipment are critical to ensuring complete stone removal. In this review we describe the technique of PCNL used in a high-volume endourology centre, where the urologist is involved in all aspects of the procedure.

Percutaneous nephrolithotomy for staghorn calculi: a single center's experience over 15 years.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) for staghorn calculi is one of the more challenging endourologic procedures. Although excellent stone-free rates are universally reported in the literature, complication rates vary widely, especially related to the need for blood transfusion. The purpose of this study was to evaluate the outcomes of PCNL for patients with staghorn calculi in a large series of patients at a single, tertiary referral, endourologic stone center. PATIENTS AND METHODS: Between July 1990 and December 2005, 1338 patients underwent PCNL for renal stone disease at our institution. Among this group, 509 procedures were performed for patients with a partial or complete staghorn calculus. Data analysis included procedure time, length of hospital stay, number of access tracts, transfusion rates, other early and late complications, and stone-free status. RESULTS: Mean patient age was 53.8 years (range 4-84 yrs). The average procedure time was 104 minutes. Sixteen percent of the cases needed multiple access tracts (range 2-5), with the lower calix being the most commonly used in 64.1%, followed by the upper calix in 18.5% and the middle calix in 17.4%. Various intracorporeal lithotriptors were used, including ultrasound, pneumatic, electrohydraulic, and holmium:yttrium-aluminium-garnet laser. The transfusion rate among this group was 0.8%. There was no statistically significant difference in transfusion rates (0.7%-1.2% P = 0.24) or other major complications in patients who were treated with either a single tract or among those needing multiple tracts. Stone-free rates at hospital discharge and at 3 months follow-up were 78% and 91%, respectively. CONCLUSION: PCNL is a safe and effective procedure in the management of staghorn calculi, with outcomes similar to those reported for percutaneous management of smaller volume nonstaghorn stones. Attention to accurate tract selection and placement as well as possession of the full array of endourologic equipment are essential to achieving an excellent outcome.

Minimizing symptoms in patients with ureteric stents.

PURPOSE OF REVIEW: The current approaches for minimizing symptoms in patients with ureteric stents were reviewed utilizing a literature search on Pubmed using the keywords stent, symptom, and ureter. RECENT FINDINGS: Ureteral stents are widely used in urological procedures for maintaining upper urinary tract drainage to relieve obstruction, pain, or infection. Indwelling stents, however, are associated with significant morbidity such as infection, encrustation, hematuria, and bothersome symptoms. Minimizing these issues has become paramount in the design of new ureteral stents. This article will review current and novel ways to minimize stent-related morbidity. SUMMARY: Currently, there is no ideal stent that relieves obstruction, is resistant to infection and encrustation, and is comfortable for patients. Advances in biomaterials and design will result in a more biocompatible stent that also has patient comfort in mind.