2022 Recommendations of The AFU Lithiasis Committee: Open surgery and laparoscopy.

Only few hundred interventions are performed in France each year to remove upper urinary tract stones using a laparoscopic/robotic transperitoneal or retroperitoneal approach. These interventions are proposed to patients with large (>20mm) and complex stones, sometimes after failure of endoscopic techniques or in the presence of malformations that can be treated at the same time. The major interest of these interventions is the possibility to remove the whole stone without prior fragmentation. Some anatomical situations can increase the technical difficulty, particularly the presence of an intrarenal pelvis and the presence of pelvic and periureteral adhesions. The reported complications are essentially urinary fistula and ureteral stenosis, the risks of which are reduced by the use of double J stenting. As struvite stones are more friable, their whole removal is more difficult and may lead to dispersion of fragments, particularly during laparoscopy. Conventional open surgery has a higher stone-free rate, but comes with a greater kidney function loss. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU Guidelines on urolithiasis. 2022) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Specific cases - chronic kidney disease, bilateral stones, and solitary kidney.

Chronic kidney disease, diabetes and hypertension are risk factors of kidney function impairment. The relative risk of kidney failure is 1.52 in patients with urinary stone disease. The various techniques used to remove upper urinary tract stones generally do not alter kidney function in patients with normal kidney function and may sometimes improve kidney function or slow its deterioration in patients with kidney disease. Compared to the asynchronous treatment of bilateral renal and ureteral stones, concomitant treatment is associated with higher risk of anuria and the need of additional interventions, in the absence of postoperative stenting. For the treatment of solitary kidney stones, the absence of postoperative stenting increases the risk of postoperative anuria. Moreover, the multiplication of percutaneous nephrolithotomy access tracts increases the risk of bleeding and that of kidney function impairment. METHODOLOGY: These recommendations were developed according to two methods: the Clinical Practice Recommendations (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Radiation protection in the operating theater.

It has been shown that the relative risk of cancer is higher in patients with urinary stone disease, probably due to the repeated radiological exams and procedures under fluoroscopic guidance. Reducing the radiation doses delivered to the patient also decreases the doses delivered to the operators and their assistants. The doses delivered during endoscopic procedures decrease with the urologist's experience. Training in radiation protection and the use of protocols can decrease the use of ionizing radiation in the operating room. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Postural therapy.

Postural therapy is a postural procedure to fight against the gravity phenomenon responsible for the non-elimination of lower calyceal stones. It allows improving or accelerating their expulsion and it increases the stone-free rate. This procedure associates forced diuresis, postural inversion, and lumbar percussion. It allows a 50% improvement and an acceleration of fragment elimination. Despite its positive impact, postural therapy remains under-used. These are the first practical recommendations on postural therapy. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they were adaptable to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Summary of indications.

The spontaneous elimination rate of ureteral stones decreases with their size, but also in function of their location. The objectives of stone surveillance are to detect the occurrence of a complication (e.g., fever, clinical tolerance) and to verify the potential stone migration/elimination. The use of urological procedures and the choice of technique are based on many different factors. Kidney stone surveillance is proposed mainly to people with low risk of progression or complications (size<4mm and/or lower calyx location and non-infection stone). Surveillance may be extended to patients with larger stones, in function of the clinical context and comorbidities. Conversely, a urological procedure may also be proposed to patients with stones<4mm for professional (e.g., soldier, pilot, expatriate) or social reasons or if travelling is planned. The choice of technique is based on the stone composition (if already known) and density, the advantages and limitations of each technique, and also the clinical context, while trying to choose the least invasive procedure for a stone-free objective. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context. This chapter is based on the references used in the chapters on the different techniques (extracorporeal shock wave therapy, ureteroscopy, percutaneous nephrolithotomy, medical expulsive therapy, postural therapy, chemolysis by alkalinization) as well as the American Urological Association (AUA) and EAU recommendations.

2022 Recommendations of the AFU Lithiasis Committee: Endoscopic description of renal papillae and stones.

Endoscopic observation is performed during treatments by flexible ureteroscopy to differentiate in situ between renal papillary abnormalities and stones based on their concordance with Daudon's morphological/composition descriptions adapted to endoscopy. These intraoperative visual analyses are now an integral part of the urinary stone disease diagnostic approach in addition to the morphological/structural and spectrophotometric analysis that remains the reference exam, but that loses information on the stone component representativeness due to the development of in situ laser lithotripsy. These are the first practical recommendations on the endoscopic description of renal papillae and stones. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Extracorporeal shock wave lithotripsy (ESWL).

Extracorporeal shock wave lithotripsy (ESWL) is a minimally invasive technique for the fragmentation of urinary tract stones using shock waves under fluoroscopic and/or ultrasound guidance. ESWL results depend on the indication (stone size/composition, clinical context) and also on how it is performed. The stone structure, nature and density (Hounsfield units; evaluated by CT without contrast agent) influence the fragmentation achieved by ESWL. The upper size limit of kidney stones has been lowered to 15mm (1.68cm3) due to the increased risk of steinstrasse with larger sizes and the potential need of anesthesia and ureteral stenting. Conversely, the development of endourological technologies allows a finer stone fragmentation and/or better elimination, thus reducing the risk of steinstrasse and decreasing the potential number of sessions or additional interventions. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Combined approach for the management of kidney and ureteral stones (Endoscopic Combined IntraRenal Surgery, ECIRS).

The primary objective of the combined approach is to limit the number of percutaneous access tracts for the treatment of staghorn, or complex kidney stones by simultaneous percutaneous antegrade and retrograde ureteroscopy. The other indication is the simultaneous presence of several kidney and ureteral stones or of an impacted pelvic stone. The combination of the two techniques may increase the stone-free rate and decrease the retreatment rate of complex stones compared with percutaneous nephrolithotomy alone. The patient is usually in the modified supine position. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

2022 recommendations of the AFU Lithiasis Committee: Objectives, results, residual stones and fragments.

The main objectives of interventional stone treatment are stone removal, symptom elimination, and kidney function preservation. After treatment of kidney stones (extracorporeal shock wave lithotripsy [ESWL], or endoscopy), fragments may remain in the kidney, either deliberately left in place or due to treatment failure (i.e. residual stone [RS], resistant to ESWL, left or inaccessible by endoscopy), or due to failure to eliminate the obtained fragments (i.e. residual fragments [RF]). Their management may differ. The most commonly used definition of RF in the literature is based on a size cut-off (≤4mm) and on three criteria: spontaneous clearance rate, secondary intervention rate, and disease progression rate. RF may be spontaneously eliminated (42%), persist and increase in size (32%), or become complicated and require a secondary urological procedure (36%). Like for the initial treatment, it is important to consider the stone composition for the treatment decision-making concerning RS/RF. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) (EAU, 2022) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Epidemiology, stone analysis and composition.

The incidence of urinary lithiasis is rising steadily in industrialized countries, and its prevalence in the general population of France is estimated at 10%. Renal colic accounts for 1-2% of emergency department consultations. At a time when the new LASER stone fragmentation techniques available to urologists will lead to ever finer in situ pulverization of stones, the exact identification of the compounds that form the stone is essential for etiological diagnosis. Constitutional analysis by infrared spectrophotometry or X-ray diffraction is therefore recommended, to be complemented by morphological typing of the calculi. METHODOLOGY: These recommendations have been drawn up using two methods: the Recommendation for Clinical Practice (RPC) method and the ADAPTE method, depending on whether or not the issue was considered in the EAU recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Diagnosis.

The choice of imaging modality is guided by the clinical presentation and the context (acute or not). Although ultrasound is safe (no radiation) and easily available, non-contrast-enhanced CT has become the gold standard in the diagnostic strategy for patients with acute flank pain because of its sensitivity (93.1%) and specificity (96.6%). It also allows determining the stone size, volume and density, visualizing their internal structure, and assessing their distance from the skin and the adjacent anatomy. All these parameters can influence the stone management and the choice of intervention modality. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendations method (CPR) and the ADAPTE method, depending on whether the issue was considered in the EAU recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Laser - utilization and settings.

Endocorporeal lithotripsy has progressed thanks to the development of lasers. Two laser sources are currently available: Holmium:YAG (Ho:YAG) and more recently Thulium Fiber Laser (TFL). The settings generally used are dusting, fragmentation, and "pop-corning". These are the first recommendations on laser use for stone management and their settings. Settings must be modulated and can be changed during the treatment according to the expected and obtained effects, the location and stone type that is treated. METHODOLOGY: These recommendations have been developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU Guidelines on urolithiasis. 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (Labate et al.) is the standard procedure for the treatment of large (≥2cm) kidney stones. The patient can be in prone or modified supine position. The puncture is performed under fluoroscopy and/or ultrasound guidance. The stone-free rate seems to be comparable between miniaturized and standard PCNL. Procedures performed with smaller diameter instruments tend to be associated with significant lower blood loss, but longer procedure times. The limitation of the number of percutaneous tracts results in better preservation of the kidney function and lowers the risk of complications. The use of tranexamic acid during PCNL may be interesting for reducing the bleeding risk, the transfusion rate, and possibly the intervention duration. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Medical management - from diagnosis to treatment.

The morphological-compositional analysis of urinary stones allows distinguishing schematically several situations: dietary, digestive, metabolic/hormonal, infectious and genetic problems. Blood and urine testing are recommended in the first instance to identify risk factors of urinary stone disease in order to avoid recurrence or progression. The other objective is to detect a potential underlying pathology associated with high risk of urinary stone disease (e.g. primary hyperparathyroidism, primary or enteric hyperoxaluria, cystinuria, distal renal tubular acidosis) that may require specific management. Lifestyle-diet measures are the basis of the management of all stone types, but pharmacological treatments may be required. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Management of symptomatic urinary stones.

The acute situation, caused by an obstructive stone, is defined by a renal colic that may be uncomplicated, complicated, or at risk in specific conditions. Its management may be medical or require interventional treatment by extracorporeal shockwave lithotripsy, endoscopic removal, or ureteroscopy. METHODOLOGY: These recommendations were developed using two methods, the Clinical Practice Recommendations (CPR) and the ADAPTE method, in function of whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and whether they could be adapted to the French context.

2022 Recommendations of the AFU Lithiasis Committee: Ureteroscopy and ureterorenoscopy.

Technical advances, including miniaturization, have improved the deflection and optical performance of the ureteroscopes, and the availability of dedicated disposable devices have led to their increasing use for kidney and ureteral stone management. Ureterorenoscopy brings diagnostic evidence through the endoscopic description of stones and renal papillary abnormalities. Currently, intracorporeal lithotripsy during ureterorenoscopy is based on laser sources. Routine ureteral stenting is not necessary before ureterorenoscopy, especially because preoperative stenting for>30 days is considered as an independent risk factor of infection. Ureteral access sheaths allow the easy and repeated access to the upper urinary tract and thus facilitate ureterorenoscopy. Their use improves vision, decreases intrarenal pressure, and possibly reduces the operative time, but they may cause ureteral injury. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether or not the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

Perioperative results of radical cystectomy after neoadjuvant chemotherapy according to the implementation of ERAS pathway.

BACKGROUND: The effect of ERAS protocols in a population of radical cystectomy (RC) patients fit for neoadjuvant chemotherapy has not been specifically explored. OBJECTIVE: To compare perioperative outcomes of open RC according to the application of an ERAS protocol in a population of patients treated by cisplatin-based NAC. METHODS: All consecutive patients treated by NAC and RC between 2016 and 2019 were included. The ERAS pathway was implemented in June 2018 and followed the EAU recommendations. All data were prospectively collected. Patients' characteristics, operative outcomes, length of stay (LOS), complication rate according to Clavien-Dindo and pathological results were compared between pre- and post-ERAS. Statistical analysis was performed using R. RESULTS: In total, 79 patients were included, 29 in the ERAS group and 50 in the non-ERAS group. A median number of 19 out of 22 ERAS criteria were followed. Mean number of NAC cycles was 4.45 vs. 4.79 in the pre- and post-ERAS groups respectively (P=0.24). Median time between NAC and RC was 3.8months. Thirty-eight percent vs. 48% of patients received an ileal neobladder in the pre- and post-ERAS group respectively (P=0.51). No differences were observed regarding operative time, blood loss or operative transfusion rates. LOS was drastically reduced in the ERAS period (18.94 vs. 12.10days, P<0.001) as well as major (>Clavien 2) complications rate (65% vs. 28%, P=0.004). CONCLUSION: ERAS drastically reduced the LOS and the rate of high-grade complications and can be effectively applied to patients receiving NAC without delaying RC.

Morbidity and long-term results of subcutaneous pyelovesical bypass in chronic ureteral obstruction.

BACKGROUND: We present the long-term results and complications of the DETOUR® prosthesis, a permanent subcutaneous pyelovesical bypass for the treatment of ureteral obstruction. PATIENTS AND METHODS: Between 2006 et 2018, 34 prosthesis were implanted in 28 patients (mean age 65,8 years) with ureteral obstruction of malignant or benign etiologies. The prosthesis, composed to an inner tube of silicone and an outer tube of expanded polytetrafluoroethylene, is placed subcutaneously between the kidney and the bladder. We are performed infrared spectrophotometry and scanning electron microscopy on two removed prostheses to explore the prosthetic encrustation. RESULTS: The average follow-up was 25,8 months (Maximum: 64 months). Stent revision was required for early bladder fistula in three patients. The major long-term complications were infection (46%), obstruction (3 patients) and bladder fistula (7 patients). The most frequently infection are non-severe, but two patients died from septic shock after fungic colonization of the prosthesis. The infrared spectrophotometry and scanning electron microscopy analysis showed that the obstruction was favored by urinary infection and an alkaline medium. The functional prosthesis rate at 1,2 and 3 years was 94%, 71% and 62%, respectively. CONCLUSION: The DETOUR® subcutaneous extra-anatomical urinary bypass is an effective and minimally invasive alternative to permanent percutaneous nephrostomy, for both malignant and benign ureteral obstructions in selected patients. LEVEL OF EVIDENCE: 3.

[Active surveillance of prostate cancer: treatement-free survival according to restricted or expanded eligibility criteria]. / Surveillance active du cancer de prostate : survie sans traitement curatif selon critères d'éligibilité stricts ou élargis.

AIM: Overtreatment is an actual problem in low risk localized prostate cancer (PC) management. Active surveillance (AS) is a solution to limit this problem, but eligibility criteria remained discussed. The aim was to assess possibilities of widening selection criteria for patient in AS, studying curative treatment free survival (CTFS) according to restricted or expanded eligibility criteria. METHODS: We retrospectively studied patients beginning AS between 2008 and 2014, for Gleason 6 localized PC, PSA<15ng/ml,

[Recommendations of the Urolithiasis Committee of the French Urology Association for the management and the treatment of the stone formers patients during the COVID-19 pandemic crisis]. / Recommandations du Comité Lithiase de l'Association Française d'Urologie pour la prise en charge des calculs urinaires durant la crise sanitaire liée à la pandémie à COVID-19.

For the first time, faced with a crisis with an exceptional magnitude due to the COVID-19 pandemic responsible for saturation of emergency services and intensive care units, the urolithiasis committee of the French Urology Association designed the recommendations for care and treatment of stone-forming patients and their treatment during crisis.