Follow-up of urolithiasis patients after treatment: an algorithm from the EAU Urolithiasis Panel.

OBJECTIVE: To develop a follow-up algorithm for urinary stone patients after definitive treatment. MATERIALS AND METHODS: The panel performed a systematic review on follow-up of urinary stone patients after treatment (PROSPERO: CRD42020205739). Given the lack of comparative studies we critically evaluated the literature and reached a consensus on the follow-up scheme. RESULTS: A total of 76 studies were included in the analysis, including 17 RCTs. In the stone-free general population group, 71-100% of patients are stone-free at 12 months while 29-94% remain stone-free at 36 months. We propose counselling these patients on imaging versus discharge after the first year. The stone-free rate in high-risk patients not receiving targeted medical therapy is < 40% at 36 months, a fact that supports imaging, metabolic, and treatment monitoring follow-up once a year. Patients with residual fragments ≤ 4 mm have a spontaneous expulsion rate of 18-47% and a growth rate of 10-41% at 12 months, supporting annual imaging follow-up. Patients with residual fragments > 4 mm should be considered for surgical re-intervention based on the low spontaneous expulsion rate (13% at 1 year) and high risk of recurrence. Plain film KUB and/or kidney ultrasonography based on clinicians' preference and stone characteristics is the preferred imaging follow-up. Computed tomography should be considered if patient is symptomatic or intervention is planned. CONCLUSIONS: Based on evidence from the systematic review we propose, for the first time, a follow-up algorithm for patients after surgical stone treatment balancing the risks of stone recurrence against the burden of radiation from imaging studies.

Consultation on UTUC II Stockholm 2022: diagnostic and prognostic methods-what's around the corner?

PURPOSE: To map current literature and provide an overview of upcoming future diagnostic and prognostic methods for upper tract urothelial carcinoma (UTUC), including translational medical science. METHODS: A scoping review approach was applied to search the literature. Based on the published literature, and the experts own experience and opinions consensus was reached through discussions at the meeting Consultation on UTUC II in Stockholm, September 2022. RESULTS: The gene mutational profile of UTUC correlates with stage, grade, prognosis, and response to different therapeutic strategies. Analysis of pathway proteins downstream of known pathogenic mutations might be an alternative approach. Liquid biopsies of cell-free DNA may detect UTUC with a higher sensitivity and specificity than urinary cytology. Extracellular vesicles from tumour cells can be detected in urine and may be used to identify the location of the urothelial carcinoma in the urinary tract. 3D microscopy of UTUC samples may add information in the analysis of tumour stage. Chemokines and chemokine receptors were linked to overall survival and responsiveness to neoadjuvant chemotherapy in muscle-invasive bladder cancer, which is potentially also of interest in UTUC. CONCLUSION: Current diagnostic methods for UTUC have shortcomings, especially concerning prognostication, which is important for personalized treatment decisions. There are several upcoming methods that may be of interest for UTUC. Most have been studied for urothelial carcinoma of the bladder, and it is important to keep in mind that UTUC is a different entity and not all methods are adaptable or applicable to UTUC.

Consultation on UTUC II Stockholm 2022: diagnostics, prognostication, and follow-up-where are we today?

PURPOSE: To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS: A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS: The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION: Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.

Fournier's gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas's NHS Foundation Trust.

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Best Practice in Interventional Management of Urolithiasis: An Update from the European Association of Urology Guidelines Panel for Urolithiasis 2022.

PURPOSE: The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis. MATERIALS AND METHODS: The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology. RESULTS: The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles. CONCLUSIONS: This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis. PATIENT SUMMARY: The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.

Long-term outcomes of outpatient laser ablation for recurrent non-muscle invasive bladder cancer: A retrospective cohort study.

Objectives: The objective of this study is to determine the long-term efficacy and safety of office-based Holmium:YAG laser ablation for the treatment of recurrent non-muscle-invasive bladder cancer (NMIBC). Methods: We retrospectively reviewed the medical records of all consecutive patients who underwent office-based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan-Meier survival curves were produced for recurrence-free survival, progression-free survival, and overall survival. Results: A total of 97 patients, with an average age of 84 (62-98) years and an average Charlson Comorbidity Index of 6.9 (4-13), were included. The median follow-up was 61 (2-150) months. Fifty-five (56.7%) patients presented with tumor recurrence, and the median recurrence-free survival time was 1.69 years (95% CI 1.20-2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low-grade tumors; however, no patient progressed to muscle-invasive disease. The median progression-free survival time was 5.70 years (95% CI 4.10-7.60), and the median overall survival time was 7.60 years (95% CI 4.90-8.70). No patient required emergency inpatient admission after laser ablation. Conclusion: Office-based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low-volume, low-grade recurrent NMIBC, especially in elderly patients with significant co-morbidity, while avoiding general anesthesia and inpatient admission.

Consultation on kidney stones, Copenhagen 2019: lithotripsy in percutaneous nephrolithotomy.

PURPOSE: To evaluate the balance between existing evidence and expert opinions on the safety and efficacy of new technological improvements in lithotripsy techniques for percutaneous nephrolithotomy (PCNL). METHODS: A scoping review approach was applied to search literature in Pubmed, Embase, and Web of Science. Consensus by key opinion leaders was reached at a 2-day meeting entitled "Consultation on Kidney Stones: Aspects of Intracorporeal Lithotripsy" held in Copenhagen, Denmark, in September 2019. RESULTS: New-generation dual-mode single-probe lithotripsy devices have shown favourable results compared with use of ballistic or ultrasonic lithotripters only. However, ballistic and ultrasonic lithotripters are also highly effective and safe and have been the backbone of PCNL for many years. Compared with standard PCNL, it seems that mini PCNL is associated with fewer bleeding complications and shorter hospital admissions, but also with longer operating room (OR) time and higher intrarenal pressure. Use of laser lithotripsy combined with suction in mini PCNL is a promising alternative that may improve such PCNL by shortening OR times. Furthermore, supine PCNL is a good alternative, especially in cases with complex renal stones and large proximal ureteric stones; in addition, it facilitates endoscopic combined intrarenal surgery (ECIRS). CONCLUSION: Recent technological improvements in PCNL techniques are promising, but there is a lack of high-level evidence on safety and efficacy. Different techniques suit different types of stones and patients. The evolution of diverse methods has given urologists the possibility of a personalized stone approach, in other words, the right approach for the right patient.

Cystinuria: clinical practice recommendation.

Cystinuria (OMIM 220100) is an autosomal recessive hereditary disorder in which high urinary cystine excretion leads to the formation of cystine stones because of the low solubility of cystine at normal urinary pH. We developed clinical practice recommendation for diagnosis, surgical and medical treatment, and follow-up of patients with cystinuria. Elaboration of these clinical practice recommendations spanned from June 2018 to December 2019 with a consensus conference in January 2019. Selected topic areas were chosen by the co-chairs of the conference. Working groups focusing on specific topics were formed. Group members performed systematic literature review using MEDLINE, drafted the statements, and discussed them. They included geneticists, medical biochemists, pediatric and adult nephrologists, pediatric and adult urologists experts in cystinuria, and the Metabolic Nephropathy Joint Working Group of the European Reference Network for Rare Kidney Diseases (ERKNet) and eUROGEN members. Overall 20 statements were produced to provide guidance on diagnosis, genetic analysis, imaging techniques, surgical treatment (indication and modalities), conservative treatment (hydration, dietetic, alkalinization, and cystine-binding drugs), follow-up, self-monitoring, complications (renal failure and hypertension), and impact on quality of life. Because of the rarity of the disease and the poor level of evidence in the literature, these statements could not be graded. This clinical practice recommendation provides guidance on all aspects of the management of both adults and children with cystinuria, including diagnosis, surgery, and medical treatment.

Non-contrast computed tomography characteristics in a large cohort of cystinuria patients.

PURPOSE: Cystine stones are widely considered hard and difficult to treat. Hounsfield Units (HU) are used in other stone types to estimate 'hardness' and treatments based on that finding. Our objective was to report mean HU of cystine stones in vivo in a large case series of cystinuria patients and assess for differences in genotype. METHODS: A prospective case series of cystinuria patients referred to a specialist centre was analysed. CT imaging was assessed by two independent radiologists to determine in vivo attenuation of cystine calculi. Mean HU was compared for both cystinuria genes (SLC3A1 and SLC7A9) using an independent t-test. RESULTS: 164 adult cystinuric patients were identified (55% male), median age 43 years (range 18-80). Median follow up was 31 months (IQR 10-62). Genetic data available for 153/164 (93%) demonstrated 97 SLC3A1 (63%) and 55 (36%) SLC7A9 mutations (39 homozygous, 16 heterozygous) and one heterozygous for both SLC3A1/SLC7A9. 107 patients had CT images available demonstrating calculi. Median HU across the cohort was 633 (5th to 95th centile 328-780). There was no difference in mean HU between SLC3A1 and SLC7A9 genotypes (p = 0.68) or homo and heterozygous SLC7A9 (p = 0.70). Mean HU correlated with stone size (Pearson correlation coefficient = 0.51, p < 0.001). CONCLUSION: In this large single centre cystinuria cohort, mean HU was low for stones that are difficult to treat. Calculi of < 800 HU should prompt consideration of a cystinuria diagnosis. Attenuation was not associated with genotype, and distinct 'smooth' and 'rough' stones were not observed. Calculi with HU > 1000 are unlikely pure cystine, and in a known cystinuric would suggest conversion to another stone type.

Imaging modalities and treatment of paediatric upper tract urolithiasis: A systematic review and update on behalf of the EAU urolithiasis guidelines panel.

BACKGROUND: Prompt diagnosis and treatment of paediatric urolithiasis are required to avoid long term sequelae of renal damage. OBJECTIVE: To systematically review the literature regarding the diagnostic imaging modalities and treatment approaches for paediatric urolithiasis. STUDY DESIGN: PubMed, Science Direct, Scopus and Web of Science were systematically searched from January 1980-January 2019. 76 full-text articles were included. RESULTS: Ultrasound and Kidney-Ureter-Bladder radiography are the baseline diagnostic examinations. Non-contrast Computed Tomography (CT) is the second line choice with high sensitivity (97-100%) and specificity (96-100%). Magnetic Resonance Urography accounts only for 2% of pediatric stone imaging studies. Expectant management for single, asymptomatic lower pole renal stones is an acceptable initial approach, especially in patients with non-struvite, non-cystine stones<7 mm. Limited studies exist on medical expulsive therapy as off-label treatment. Extracorporeal shock wave lithotripsy (SWL) is the first-line treatment with overall stone free rates (SFRs) of 70-90%, retreatment rates 4-50% and complication rates up to 15%. Semi-rigid ureteroscopy is effective with SFRs of 81-98%, re-treatment rates of 6.3-10% and complication rates of 1.9-23%. Flexible ureteroscopy has shown SFRs of 76-100%, retreatment rates of 0-19% and complication rates of 0-28%. SFRs after first and second-look percutaneous nephrolithotomy (PNL) are 70.1-97.3% and 84.6-97.5%, respectively with an overall complication rate of 20%. Open surgery is seldom used, while laparoscopy is effective for stones refractory to SWL and PNL. Limited data exist for robot-assisted management. CONCLUSIONS: In the initial assessment of paediatric urolithiasis, US is recommended as first imaging modality, while non-contrast CT is the second option. SWL is recommended as first line treatment for renal stones <20 mm and for ureteral stones<10 mm. Ureteroscopy is a feasible alternative both for ureteral stones not amenable to SWL as well as for renal stones <20 mm (using flexible). PNL is recommended for renal stones >20 mm.

Evaluation and Medical Management of Patients with Cystine Nephrolithiasis: A Consensus Statement.

Purpose: Cystinuria is a genetic disorder with both autosomal recessive and incompletely dominant inheritance. The disorder disrupts cystine and other dibasic amino acid transport in proximal tubules of the kidney, resulting in recurrent kidney stone formation. Currently, there are no consensus guidelines on evaluation and management of this disease. This article represents the consensus of the author panel and will provide clinicians with a stepwise framework for evaluation and clinical management of patients with cystinuria based on evidence in the existing literature. Materials and Methods: A search of MEDLINE®/PubMed® and Cochrane databases was performed using the following key words: "cystine nephrolithiasis," "cystinuria," "penicillamine, cystine," and "tiopronin, cystine." In total, as of May 2018, these searches yielded 2335 articles, which were then evaluated for their relevance to the topic of evaluation and management of cystinuria. Evidence was evaluated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Results: Twenty-five articles on the topic of cystinuria or cystine nephrolithiasis were deemed suitable for inclusion in this study. The literature supports a logical evaluation process and step-wise treatment approach beginning with conservative measures: fluid intake and dietary modification. If stone formation recurs, proceed to pharmacotherapeutic options by first alkalinizing the urine and then using cystine-binding thiol drugs. Conclusions: The proposed clinical pathways provide a framework for efficient evaluation and treatment of patients with cystinuria, which should improve overall outcomes of this rare, but highly recurrent, form of nephrolithiasis.

Cost analysis of ureteroscopy (URS) vs extracorporeal shockwave lithotripsy (ESWL) in the management of ureteric stones <10 mm in adults: a UK perspective.

OBJECTIVES: To compare the total cost of a treatment strategy starting with ureteroscopy (URS) vs a strategy starting with extracorporeal shockwave lithotripsy (ESWL). METHODS: For ureteric stones of <10 mm, URS or ESWL are the main treatment options that are considered. Although the interventions differ, the goal of the interventions is to achieve a stone-free status. A systematic review and meta-analysis undertaken as part of the National Institute for Health and Care Excellence (NICE) guideline on 'Renal and ureteric stones: assessment and management' identified URS as more effective, in terms of getting people stone free, but has a higher probability of re-admission and adverse events (AEs) that contributes to downstream resource use. ESWL is initially less costly, but lower effectiveness means a greater need for repeat or ancillary procedures in order to get a patient stone free. Given these trade-offs between benefits and costs, a cost analysis of URS and ESWL was undertaken as part of the NICE guideline, using evidence from the literature of effectiveness, re-admission and AEs. The NICE guideline meta-analysis showed a lot of heterogeneity and differences in how outcomes were reported between studies. The costing analysis, therefore only used studies where: (i) patients were rendered stone free, and (ii) where effectiveness, was based on the first-line (initial) procedures. Exploratory quality adjusted life year (QALY) work was also undertaken to identify the QALY and quality of life (QoL) differences required for the most expensive intervention to be cost effective, based on the assumption that the difference in effectiveness between the initial procedures would be the main source of the QALY gain between the two strategies. RESULTS: The URS strategy was more costly overall than the ESWL strategy (incremental cost of £2387 [pounds sterling]). Sensitivity analysis varying the initial effectiveness of ESWL treatment (between the base case value of 82% and 40%) showed that URS would still be a more costly strategy even if the initial session of ESWL only had a success probability of 40%. A two-way sensitivity analysis as part of the exploratory QALY work showed that ESWL would have to have very low effectiveness and people would have to wait for further treatment for many weeks (following a failed ESWL treatment) for there to be feasible QoL gains to justify the additional cost of the URS strategy. CONCLUSIONS: ESWL is less effective at initial stone clearance and therefore requires more ancillary interventions than URS. However, the magnitude of the difference in costs means URS is unlikely to be cost effective intervention at a population level for first-line treatment, implying ESWL should be the first choice treatment.

Treatment of Bladder Stones in Adults and Children: A Systematic Review and Meta-analysis on Behalf of the European Association of Urology Urolithiasis Guideline Panel.

CONTEXT: Bladder stones (BS) constitute 5% of urinary stones. Currently, there is no systematic review of their treatment. OBJECTIVE: To assess the efficacy (primary outcome: stone-free rate [SFR]) and morbidity of BS treatments. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with the European Association of Urology Guidelines Office. Database searches (1970-2019) were screened, abstracted, and assessed for risk of bias for comparative randomised controlled trials (RCTs) and nonrandomised studies (NRSs) with ≥10 patients per group. Quality of evidence (QoE) was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. EVIDENCE SYNTHESIS: A total of 2742 abstracts and 59 full-text articles were assessed, and 25 studies (2340 patients) were included. In adults, one RCT found a lower SFR following shock wave lithotripsy (SWL) than transurethral cystolithotripsy (TUCL; risk ratio 0.88, p=0.03; low QoE). Four RCTs compared TUCL versus percutaneous cystolithotripsy (PCCL): meta-analyses demonstrated no difference in SFR, but hospital stay (mean difference [MD] 0.82d, p<0.00001) and procedure duration (MD 9.83min, p<0.00001) favoured TUCL (moderate QoE). Four NRSs comparing open cystolithotomy (CL) versus TUCL or PCCL found no difference in SFR; hospital stay and procedure duration favoured endoscopic surgery (very low QoE). Four RCTs compared TUCL using a nephroscope versus a cystoscope: meta-analyses demonstrated no difference in SFR; procedure duration favoured the use of a nephroscope (MD 22.74min, p<0.00001; moderate QoE). In children, one NRS showed a lower SFR following SWL than TUCL or CL. Two NRSs comparing CL versus TUCL/PCCL found similar SFRs; catheterisation time and hospital stay favoured endoscopic treatments. One RCT comparing laser versus pneumatic TUCL found no difference in SFR. One large NRS comparing CL techniques found a shorter hospital stay after tubeless CL in selected cases; QoE was very low. CONCLUSIONS: Current available evidence indicates that TUCL is the intervention of choice for BSs in adults and children, where feasible. Further high-quality research on the topic is required. PATIENT SUMMARY: We examined the literature to determine the most effective and least harmful procedures for bladder stones in adults and children. The results suggest that endoscopic surgery is equally effective as open surgery. It is unclear whether stone size affects outcomes. Shock wave lithotripsy appears to be less effective. Endoscopic treatments appear to have shorter catheterisation time and convalescence compared with open surgery in adults and children. Transurethral surgery, where feasible, appears to have a shorter hospital stay than percutaneous surgery. Further research is required to clarify the efficacy of minimally invasive treatments for larger stones and in young children.

Surgery for high-risk locally advanced (pT3c) renal tumours: oncological outcomes and prognostic significance of a modified International Metastatic Renal Cell Cancer Database Consortium (IMDC) score.

OBJECTIVES: To evaluate contemporary oncological outcomes and long-term survival in patients undergoing surgery for urological tumours involving the peridiaphragmatic inferior vena cava up to the level of the right atrium. To apply prognostic factors developed for metastatic renal cancer to patients with very-high-risk but apparently localized tumours, and develop a scoring system. PATIENTS AND METHODS: A retrospective cohort study of 54 patients referred between December 2007 and April 2018 to a single surgical and oncological team was conducted. Electronic patient records were used to obtain peri-operative data and oncological follow-up. For operated patients lost to follow-up, survival data were obtained from primary care physicians. We used Kaplan-Meier curves to estimate overall survival (OS) and disease-free survival. For the subgroup undergoing curative surgery (n = 32) the prognostic value of a renal cancer score developed at Guy's Hospital using five of the six criteria in the International Metastatic Renal Cell Carcinoma Database Consortium prognostic model (one point for each of anaemia, neutrophilia, thrombophilia, hypercalcaemia and Karnofsky performance status <80), in order to be relevant for M0 disease, was assessed using the log-rank test. RESULTS: The median (interquartile range [IQR]) OS of the whole cohort was 29 (11-57) months. The median (IQR) survival of the curative subgroup (n = 32) was 32 (16-57) months, vs 11 (4-upper limit not reached) months for the cytoreductive subgroup (n = 13; P = 0.14). The median (IQR) follow-up time was 14 (1-65) months for patients alive at analysis. Disease-free survival in the curative subgroup was 10 (6-30) months. The median (IQR) OS by risk category for curative cases, as defined by the Guy's renal cancer score, was not reached in the favourable risk group (score = 0 points) because there were no patient deaths, 43 (30-61) months in the intermediate-risk group (score = 1 point), and 18 months (11-32) months in the poor-risk group (score ≥ 2 points; P = 0.005). CONCLUSION: A median survival of 29 months appears to justify this type of surgery. A prognostic model, the Guy's renal cancer score, using five readily available clinical measures, appears promising in patients with very-high-risk locally advanced tumours.