Measuring quality of life in patients with kidney stone disease: is it the future in endourology?

PURPOSE OF REVIEW: Kidney stone disease is recognized to negatively impact quality of life. This pertains to acute episodes, surgical interventions and even during asymptomatic periods. Over time there has been increased attention towards assessing this subjective parameter, including as a determinant of treatment success. Our aim was to evaluate the current status and emerging trends in this field. RECENT FINDINGS: Patient groups most affected appear to be recurrent stone formers, cystine stone formers, women, younger populations, non-Caucasians and low-income populations. Several stone specific patient reported outcome measures are now available of which, WISQol has been implemented the most in clinical research studies. More invasive interventions such as percutaneous nephrolithotomy impede quality of life to greater extent than alternatives such as shockwave lithotripsy. SUMMARY: There are certain patient groups who are more vulnerable to the negative impact of kidney stone disease on their quality of life. Urologists can improve patient care by recognizing these particular populations as well as by implemented patient reported outcome measures in their routine clinical practice and when performing research.

Chinese mini percutaneous nephrolithotomy for upper urinary calculi under local infiltration anesthesia.

Percutaneous nephrolithotomy is generally performed under general or regional anesthesia; however, it is rarely performed under local infiltration anesthesia (LIA). This study aimed to assess the safety and effectiveness of Chinese mini percutaneous nephrolithotomy (MPCNL) for upper urinary calculi under LIA. A retrospective analysis of 52 patients with upper urinary stones who underwent MPCNL under LIA from April 2019 to May 2022 was performed. Pethidine and Phenergan were intramuscularly injected 30 minutes preoperatively. Oxybuprocaine hydrochloride gel was applied to the urethra for lubricating and mucosal anesthesia. Ropivacaine hydrochloride and lidocaine were injected into the whole percutaneous channel for local anesthesia. An 8/9.8F ureteroscope and an 18F vacuum-assisted access sheath were applied in MPCNL. All 52 patients tolerated procedures and underwent operations successfully; none of them converted the anesthesia method or required additional analgesia. The mean visual analogue scale scores intraoperatively and at 6 hours, 24 hours, and 48 hours after surgery were 3.25 ± 0.52, 3.13 ± 0.69, 2.25 ± 0.56, and 1.58 ± 0.50, respectively. The stone free rate was 84.6%. Complications were seen in 6 (11.5%) patients, including fever in 2 patients (Clavien I), renal colic in 1 patient (Clavien I), clinically insignificant bleeding in 2 patients (Clavien I), and urinary tract infection in 1 patient (Clavien II). No severe complications were observed in any patients. Chinese MPCNL under LIA was a feasible option and achieved good outcomes in appropriately selected patients, and it may become the routine procedure for general patients.

Analysis of the Efficacy and Safety of PCNL and ESWL in Patients with Complicated Upper Urinary Tract Renal Calculi.

Objective: This study aimed to investigate the clinical efficacy and safety of combining percutaneous nephrolithotomy (PCNL) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of patients with complicated upper urinary calculi. Methods: We employed a randomized controlled experimental design to examine data from patients diagnosed with complex upper urinary tract renal calculi at our hospital from April 2019 to March 2020. A total of 98 eligible patients were included in the study. To ensure the integrity of the research, we computerized and randomized the patient data according to the study's protocol. Subsequently, we divided the patients into two groups: a control group (n = 49) that received ESWL as the treatment modality and an experimental group (n = 49) that underwent a combined treatment approach involving both PCNL and ESWL. Following the completion of the treatments, we analyzed stone clearance rates and other outcome indicators. Additionally, we carefully documented any post-treatment adverse events to evaluate patient safety comprehensively. Results: The experimental group exhibited a higher stone clearance rate compared to the control group. Comparison of visual Analog Scale/Score (VAS) pain scores, operation time, and hospitalization time revealed statistically significant differences (P < .05), with the experimental group showing slightly worse performance than the control group. After treatment, both groups experienced varying degrees of complications, with the experimental group demonstrating fewer complications, a statistically significant result (P < .05). Conclusions: Extracorporeal shock wave lithotripsy significantly improved stone clearance rates in patients with complex upper urinary tract renal calculi. Simultaneously, it positively impacted surgical outcomes and reduced the incidence of post-treatment adverse events. This intervention offers clinical benefits.

Outcomes of Percutaneous Nephrolithotomy Under Local Anesthesia: Outcomes of a Systematic Review of Literature.

Background: Several studies have reported on the safety and feasibility of percutaneous nephrolithotomy (PCNL) under local anesthesia (LA). The aim of this systematic review is to assess the perioperative outcomes of PCNL under LA. Methods: Three electronic databases, including MEDLINE, EMBASE, and Web of Science, were searched for relevant English-language studies published from January 1980 to March 2023. The systematic review has been performed according to the Cochrane style and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The primary outcomes include stone-free rate (SFR) and conversion to general anesthesia (GA). Secondary outcomes include postoperative complications. Results: Of 301 articles that were extracted, 42 full-text articles were selected, of which 36 were excluded, yielding a total of 6 articles in our results. A total of 3646 patients were included in this review. The SFR of PCNL under LA ranged between 69.9% and 93.3%. PCNL under LA was not tolerated by 19 (0.5%) patients: 6 patients had conversion to general anesthesia, 2 had conversion to epidural anesthesia, and 11 had their procedure terminated. The overall complication rates varied from 4.8% to 21% across studies. Grade I-II complications were reported in 2.4%-16.7% of cases, while grade III-IV complications were encountered in 0.5%-5% of patients. Conclusions: In this review, we found a few studies that examined the outcomes of PCNL under LA, which highlight the feasibility and safety of PCNL under LA and the low conversion rate to GA.

Is laparoscopic pyelolithotomy an alternative to percutaneous nephrolithotomy for treatment of kidney stones larger than 2.5 cm in pediatric patients?

PURPOSE: The aim was to compare laparoscopic pyelolithotomy and percutaneous nephrolithotomy in terms of efficacy and safety for the treatment of renal pelvis stones larger than 2.5 cm in pediatric patients. METHODS: Our study consisted of two groups. Group 1 included 33 patients who underwent laparoscopic pyelolithotomy (LPL) between January 2013 and March 2022, and group 2 included 39 patients who underwent percutaneous nephrolithotomy (PCNL). The basic clinical parameters of the patients were recorded. Mean operation time, stone size, estimated blood loss, blood transfusion rate, postoperative hospital stay, stone-free rate, postoperative analgesia requirements, intraoperative complications, and early and late postoperative complications were compared between the two groups. RESULTS: In our study, the mean age of the patients in groups 1 and 2 was 8.89 ± 1.58 years and 9.1 ± 1.85 years, respectively (p = 0.657). The mean stone size was 2.37 ± 0.38 cm in group 1 and 2.55 ± 0.45 cm in group 2 (p = 0.64). The mean operation time was 85.65 ± 20.55 min in group 1, while it was 76.11 ± 13.12 min in group 2 (p = 0.08). The stone-free rate was 100% in both groups. Intraoperative mean blood loss, need for postoperative analgesia, blood transfusion and intraoperative complication rates were significantly higher in the PCNL group (p < 0.01, p = 0.02, p < 0.01, p < 0.01, respectively). CONCLUSION: Our results show that laparoscopic pyelolithotomy is a safe and effective method for pediatric patients with large kidney stones.

Aplicación tópica de ácido tranexámico en urología: ¿Una alternativa de manejo? / Topical Application of Tranexamic Acid in Urology: An Alternative Management?

Los agentes antifibrinolíticos, como el ácido tranexámico, por medio de su administración endovenosa se usan en distintos procedimientos quirúrgicos para prevenir la pérdida de sangrado perioperatorio.[1] Este medicamento es un derivado sintético análogo de la lisina que bloquea los sititos de unión de la lisina en el plasminógeno, inhibiendo su conversión a plasmina e interfiriendo en la fibrinólisis.[2] La aplicación del ácido tranexámico para disminuir el riesgo de sangrado ha sido utilizado en procedimientos urológicos como la resección transuretral prostática (RTUP), prostatectomía radical y nefrolitotomía percutánea (NLP),[3] [4] [5] también se emplea para disminuir las hematurias persistentes en pacientes con poliquistosis renal y en otras hematurias macroscópicas de origen urológico.

Antifibrinolytic agents, such as tranexamic acid, by intravenous administration are used in various surgical procedures to prevent perioperative bleeding loss.[1] This drug is a synthetic lysine analog derivative that blocks the lysine binding sites on plasminogen, inhibiting its conversion to plasmin and interfering with fibrinolysis.[2] The application of tranexamic acid to reduce the risk of bleeding has been used in urological procedures such as transurethral resection of the prostate (TURP), radical prostatectomy and nephrolithotomy. The application of tranexamic acid to reduce the risk of bleeding has been used in urological procedures such as transurethral resection of the prostate (TURP), radical prostatectomy and percutaneous nephrolithotomy (PNL),[3] [4] [5] it is also used to reduce persistent hematuria in patients with polycystic kidney disease and other macroscopic hematuria of urological origin.

Minipercutaneous Nephrolithotomy Under Mixture of Local Anesthesia: A Randomized Controlled Study.

Objective: To evaluate the safety, efficacy, and feasibility of minipercutaneous nephrolithotomy (MPCNL) under mixture of local anesthetics (MLA) vs spinal anesthesia (SA) for management of large renal stones. Patients and Methods: This study was a prospective randomized controlled study and approved by IRB (REC-FOMBU). A total of 120 consecutive patients who met the inclusion criteria of the study and agreed to sign the informed consent form were randomized to undergo MPCNL under MLA (60 patients) or SA (60 patients). Intra- and postoperative findings including visual pain analogue scale (VAS), operative time, hospital stay, adverse events (AEs), stone-free rate, and related data were recorded. Results: Baseline characteristics and demography included age and gender; stone's site, size, and density were comparable for both groups (p > 0.05). The average VAS scores in the MLA group at 0, 2, 6, 12, and 24 hours were 2.5, 0, 1, 1, and 0, respectively. The corresponding values in the SA group were 2, 1, 2, 2, and 1, respectively, (p < 0.05). The average operation time was ∼1 hour for both groups and the length of hospital stay was 1.5 days for both groups (p > 0.05). Whereas the mean hemoglobin deficit was 1.04% ± 0.54% vs 1.27 ± 0.46 (p = 0.013) and the primary postoperative stone clearance was 93.4% vs 88.3% (p > 0.05), for MLA and SA groups, respectively. Postoperative analgesic consumption and complications were similar in the MLA and SA groups. Conclusion: Single tract MPCNL is feasible under either MLA or SA with comparable stone clearance and AEs. Perioperative VAS was similar and acceptable for both modalities.

Comparison of Mini Percutaneous Nephrolithotomy (Mini PCNL) and Retrograde Intrarenal Surgery (RIRS) for the Minimal Invasive Management of Lower Caliceal Stones.

PURPOSE:   To evaluate the stone-free rates, quality of life, complications, use of fluoroscopy, analgesic requirements, a hospital stay following the management of lower calyceal with two different techniques (Mini Percutaneous Nephrolithotomy and Retrograde Intrarenal Surgery) in a prospective manner. MATERIAL AND METHODS: 50 patients with a diagnosis lower pole 1-2 cm stone were included into the study and were randomized into two groups.(Mini PCNL n: 25) ( RIRS n: 25). Safety and efficacy of both methods along with some other certain related factors were comparatively evaluated in both groups. RESULTS:  There was no significant difference between preoperative stone size, stone to skin distance, hemogram and creatinine values, need for analgesic drug, patients' replies to visual analog scale (VAS). The duration of both the hospital stay and the exposure to fluoroscopy, hematocrit decrease due to hemorrhage, complication rates were significantly higher in cases undergoing mini PCNL when compared to RIRS. Additionally, any significant difference was not observed with respect to the stone-free rates. Despite an increase in quality of life following the both type operations was noted; there was no significant difference in the quality of life between the patients in both groups. CONCLUSION:  Our findings demonstrated that both surgical techniques are the feasible alternatives in the minimal invasive treatment of lower pole stones. Although there was no meaningful difference in stone-free rates between two groups; complications, use of fluoroscopy, bleeding and duration of hospital stay were noted to be significantly higher in cases treated with mini PCNL.

The feasibility of multiple-tract mini-percutaneous nephrolithotomy as an overnight surgery for the treatment of complex kidney stones.

To demonstrate the feasibility of applying multiple-tract percutaneous nephrolithotomy (PCNL) as an overnight surgery for treatment of complex kidney stones. We reviewed a prospectively collected database of all multiple-tract PCNL planned as overnight surgery performed by a single surgeon since 2018. A clinical pathway including the removal of nephrostomy tube and discharge on the morning after surgery was carried out. A definition for tube removal was outlined. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined. A total of 136 consecutive patients were enrolled with mean stone burden of 960.5 mm2 and 5.1 cm. Mean operative time was 71.7 ± 30.7 min. The average hemoglobin drop was 17.6 ± 12.2 g/L, and the incidence of drop > 25 g/L was 21.9%. Overall, 125 patients (91.9%) but 11 patients were discharge on postoperative day 1. One case required readmission. Among the 11 patients, 7 patients (5.1%) underwent a delayed tube removal (≥ 2 days) and 4 patients underwent complications after next-day nephrostomy tube removal, including renal colic (2 cases), hydrothorax (1 case), and fever (1 case). Postoperative fever or severe hematuria was the major reason for delayed nephrostomy tube removal. The total complication rate was 8.8% (n = 12). Multiple-tract PCNL as an overnight surgery can be safely performed by experienced surgeons in most patients. An early nephrostomy tube removal could be achieved in nearly 95% patients.

Effectiveness of Aromatherapy for Relief of Pain, Nausea, and Vomiting after Percutaneous Nephrolithotomy: A Randomized Controlled Trial.

BACKGROUND: Postoperative pain, nausea, and vomiting are common side effects of percutaneous nephrolithotomy. Nowadays, non-pharmacological and complementary therapies have been noticed. Therefore, a study was conducted to determine the effectiveness of lavender and clary sage on the pain, nausea, and vomiting after percutaneous nephrolithotomy. METHODS: This is a randomized clinical trial study on 79 patients undergoing percutaneous nephrolithotomy. Patients were randomly divided into three groups of lavender aromatherapy (n = 27), clary sage aromatherapy (n = 26), and a control group (n = 26). Each of the intervention groups received the inhalation aromatherapy immediately and 3 and 6 h after the operation. Pain, nausea, and emetic episodes in patients of the three groups were measured before the intervention and 30 min after each intervention using a visual analog scale and checklist. RESULTS: Pain decreased significantly in the clary sage aromatherapy group. Nausea had a downward trend in the two groups of aromatherapy. The lavender aromatherapy group had the lowest incidence of emetic episodes compared to the other groups. CONCLUSION: Regarding the annoying pain, nausea, and vomiting after percutaneous nephrolithotomy for patients, and taking into account the complications of drug therapy, the use of complementary non-pharmacological methods can help increase the comfort of patients.

PCNL in COPD patient in the sit position under local infiltration anesthesia case report.

BACKGROUND: Percutaneous nephrolithotomy is traditionally performed in the prone or supine position. We report the first case of percutaneous nephrolithotomy in sit position under local infiltration anesthesia. A 69-year-old male presented with left flank pain. Kidney B ultrasound and computed tomography scan showed multiple left renal calculi and hydronephrosis. He had a long history of chronic obstructive pulmonary disease, with severe ventilatory and cardiac dysfunction, and cannot tolerate the prone or supine position. The patient received the surgery in sit position under local infiltration anesthesia. The operative time was 1 h. The visual analogue scale score during the surgery was 3. The patient had no intraoperative and postoperative complications. The postoperative plain radiography showed no residual stone fragments. CONCLUSIONS: We believe that in high-risk patients who need to undergo PCNL, a combination of sit position and local infiltration anesthesia is an alternative method.

Percutaneous Nephrolithotomy under Local Infiltration Anesthesia in Kneeling Prone Position for a Patient with Spinal Deformity.

Urolithiasis, a common condition in patients with spinal deformity, poses a challenge to surgical procedures and anesthetic management. A 51-year-old Chinese male presented with bilateral complex renal calculi. He was also affected by severe kyphosis deformity and spinal stiffness due to ankylosing spondylitis. Dr. Li performed the percutaneous nephrolithotomy under local infiltration anesthesia with the patient in a kneeling prone position, achieving satisfactory stone clearance with no severe complications. We found this protocol safe and effective to manage kidney stones in patients with spinal deformity. Local infiltration anesthesia may benefit patients for whom epidural anesthesia and intubation anesthesia are difficult.

Ultra-Mini-Percutaneous Nephrolithotomy for the Treatment of Upper Urinary Tract Stones Sized between 10-20 mm in Children Younger Than 8 Years Old.

PURPOSE: With the invention of miniature devices, it has been advised to apply less aggressive methods for the management of upper urinary tract stones, especially in children. In the recent years, ultra-mini percutaneous nephrolithotomy (UMP) has been used for the treatment of upper urinary tract stones in order to perform surgeries with less complications and more acceptable outcomes. Results reported from different medical centers have been promising. MATERIALS AND METHODS: Twenty-two children aged less than 8 years old with upper urinary stones sized between 10-20 mm underwent UMP. Inclusion criteria was solitary unilateral kidney stone, stone size between 10-20 mm, normal renal function tests, absence of any congenital malformations, and history of previous ESWL failure. Data including age, sex, side of kidney involvement, size of stone, location of stone, duration of surgery, duration of hospitalization, stone composition, need for blood transfusion, damage to adjacent organs, postoperative fever, septicemia after surgery, need for narcotics, further need for a complementary method, stone-free rate, pre and post-operative hemoglobin levels, and urinary leakage from the access tract were extracted from patients' medical files and were recorded. RESULTS: The mean age (± standard deviation) of children was 5.22 (±1.57) years. Fourteen (63.6%) patients were male. Fifteen (68.2%) renal stones were located in the right kidney, and 82% of patients had pelvis stones. 13 (59%) patients' stones were composed of calcium oxalate. Stone-free rate was 95.5%. In none of the cases urinary leakage, septicemia after surgery, injury to adjacent organs, and need for blood transfusions was reported. CONCLUSION: Ultra-mini percutaneous nephrolithotomy is an efficient and safe method for treating urinary stones sized between 10-20 mm in children.

Predictive factors of stone-free rate and complications in patients undergoing minimally invasive percutaneous nephrolithotomy under local infiltration anesthesia.

PURPOSE: To evaluate predictive factors affecting the stone-free rates (SFR) and complications of minimally invasive percutaneous nephrolithotomy (MPCNL) under local infiltration anesthesia (LIA) METHODS: A retrospective analysis was conducted on 976 consecutive patients who underwent MPCNL under LIA from January 2015 to June 2018. Postoperative complications were classified according to modified Clavien classification system. Univariate and multivariate logistic regression analyses were used to determine factors affecting SFR and complications. RESULTS: The pain was acceptable with postoperative visual analog scale (VAS) scores being 3.58, 2.99, 2.25, and 2.07 after 0, 6, 24, and 48 h, respectively. The SFR after primary MPCNL reached 85.7%. Postoperative complications were recorded in 77 patients (7.9%). In the univariate logistic analysis, larger stone size, staghorn stone, and multiple calyxes were significantly associated with lower SFR. The higher American Society of Anesthesiologists (ASA) score, staghorn stone, positive urine culture, multiple tracts, and longer operation time were associated with occurrence of complications. However, hydronephrosis was associated with lower complication rate. Multivariate analysis indicated that larger stone size (P < 0.001) and staghorn stone (P < 0.001) were associated with lower SFR, while development of complications was independently influenced by higher ASA score (P = 0.002), multiple tract (P = 0.004), and staghorn stone (P = 0.028). CONCLUSIONS: MPCNL can be safely and effectively performed under LIA. Stone size and staghorn stone are factors associated with SFR while ASA score, multiple tracts, and staghorn stone are associated with the development of complications. For the first time, we developed a model to predict the SFR and complications in MPCNL under LIA.

Ultrasound-guided low thoracic paravertebral block versus peritubal infiltration for percutaneous nephrolithotomy: a prospective randomized study.

The aim of this study was to investigate the efficacy of peritubular infiltration and ultrasound-guided low thoracal paravertebral block in patients undergoing percutaneous nephrolithotomy (PCNL). Sixty patients, American Society of Anesthesiologists I-II, between the ages of 18 and 65 years undergoing PCNL were randomized into three groups. Group peritubal infiltration (Pi, n = 20) received infiltration along the nephrostomy tube 20 ml 0.25% bupivacaine, in 6 and 12 o'clock position. Group paravertebral block (Pv, n = 20) received single-shot paravertebral block with 20 ml 0.25% bupivacaine at the level of T8-T9. Group control (C, n = 20): no intervention is performed. Postoperative opioid consumption and pain scores, opioid-related side effects, and additional analgesic requirement were recorded. The fentanyl consumption in Group Pv was significantly lower in comparison to Group C in all time intervals (p < 0.05). In the comparison of Group Pv and Group Pi, fentanyl consumptions in the postoperative 0-4th hours (100.00 ± 50.65 and 145.00 ± 61.55, respectively), 4-8th hours (50.00 ± 64.88 and 121.25 ± 56.93 respectively), and in the total of 24 h (197.50 ± 133.74 and 368.75 ± 116.66 respectively) were significantly lower in Group Pv (p < 0.05). The dynamic VAS scores analyzed at the 1st and 2nd hours were significantly lower in Group Pv than Group Pi (p < 0.05). Eight patients in Group C, two patients in Group Pi and 1 patient in Group Pv required additional analgesics and the difference was significant (p < 0.05). Paravertebral block achieved more effective analgesia by reducing postoperative opioid consumption and VAS scores comparison to the control and peritubal infiltration groups in patients undergoing percutaneous nephrolithotomy.