Impact of Either Trendelenburg or Reverse Trendelenburg Positioning for Ureteroscopy Lithotripsy Procedures: A Systematic Review and Meta-Analysis.

PURPOSE: Urologists encounter multiple challenges in managing ureteral stones with ureteroscopic laser lithotripsy. This meta-analysis assesses the effectiveness of alternative surgical positioning, Reverse Trendelenburg (RevTren) and Trendelenburg (Tren), in reducing stone migration and enhancing outcomes compared with standard dorsal lithotomy positioning. MATERIALS AND METHODS: A systematic review was conducted following PRISMA guidelines, searching Medline, Embase, Scopus, Cochrane, and WoS up to March 2024. This review focused on studies evaluating RevTren or Tren positioning during ureteroscopic lithotripsy compared with standard dorsal lithotomy, analyzing end points such as stone migration, conversion rates, success rates, complications, and operative time. RESULTS: Of 137 studies identified, 8 met the inclusion criteria, encompassing 1374 patients. RevTren significantly reduced ureteral stone migration (odds ratio [OR], 0.20; 95% CI, 0.08-0.47), lowered the need for conversion to a flexible ureteroscope (OR, 0.28; 95% CI, 0.12-0.67), and improved success rates (OR, 2.90; 95% CI, 1.88-4.48). Tren increased migration of ureteral and calyceal stones toward upper renal calyces (OR, 2.12; 95% CI, 1.48-3.04) and achieved a higher success rate (OR, 3.56; 95% CI, 2.15-5.92). Complications were comparable across all positions. CONCLUSION: Adjusting patient positioning during ureteroscopic laser lithotripsy can enhance procedure outcomes. RevTren effectively reduces ureteral stone migration and the necessity for flexible ureteroscopes, whereas Tren facilitates ureteral and calyceal stone migration toward upper calyces, increasing success rates. Both positioning techniques offer significant advantages over standard positioning and can be safely adopted in clinical practice without compromising patient safety.

Decompressive Craniectomy with or Without Dural Closure: Systematic Review and Meta-analysis.

Decompressive craniectomy is used to alleviate intracranial pressure in cases of traumatic brain injury and stroke by removing part of the skull to allow brain expansion. Traditionally, this procedure is followed by a watertight dural suture, although evidence supporting this method is not strong. This meta-analysis examines the feasibility of the open-dura (OD) approach versus the traditional closed-dura (CD) technique with watertight suturing. A systematic review and comparative meta-analysis were conducted on OD and CD dural closure techniques. Medline, Embase, and Cochrane were searched for relevant trials. The primary end point was the rate of complications, with specific analyses for infection and cerebrospinal fluid (CSF) leaks. Mortality, poor neurological outcomes, and operation duration were also assessed. Odds ratios with 95% confidence intervals (CIs) were calculated using a random-effects model. Following a comprehensive search, 930 studies were screened, from which four studies and a total of 368 patients were ultimately selected. The primary outcome analysis showed a reduced likelihood of complications in the OD group when compared with the CD group (368 patients, odds ratio 0.54 [95% CI 0.32-0.90]; I2 = 17%; p < 0.05). Specific analysis of infections and CSF leaks did not show statistically significant results, as well as the evaluation of the mortality rates and poor neurological outcome differences between groups. Assessment of operation duration, however, demonstrated a significant difference between techniques, with a mean reduction of 52.50 min favoring the OD approach (mean difference - 52.50 [95% CI - 92.13 to - 12.87]; I2 = 96%). This study supports the viability of decompressive craniectomy without the conventional time-spending watertight duraplasty closure, exhibiting no differences in the rate of infections or CSF leaks. Furthermore, this approach has been associated with improved rates of complications and faster surgery, which are important aspects of this technique, particularly in its potential to reduce both costs and procedure length.

Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis.

BACKGROUND: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. RESULTS: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. CONCLUSION: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.

Effect of irrigation solution temperature on complications of percutaneous nephrolithotomy: a systematic review of the literature, meta-analysis and trial sequential analysis of randomized clinical trials.

INTRODUCTION: The optimal temperature of irrigation solution in patients undergoing PCNL is still unclear. Accordingly, this study aims to investigate the effects of different irrigation solution temperatures (cold/room temperature irrigation fluid versus warm/body temperature fluid). Our primary endpoint was hypothermia rate. Secondary outcomes were shivering rate, mean temperature decrease, mean patient final temperature, blood loss, and operative time. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were searched in November 2023. Among 299 studies screened, eight were selected for full-text review, resulting in four randomized clinical trials that fit inclusion criteria and desired outcomes. Studies selection and data extraction were performed by multiple reviewers and a random-effects model was used for pooling of data. EVIDENCE SYNTHESIS: The primary outcome, hypothermia rate, showed a significant statistical difference between groups, occurring less frequently in the experimental group (35-37 ºC) than in the cold/room temperature irrigation group (RR 0.64;95%CI 0.46, 0.89; P<0.008; I2=33%). Secondary outcomes such as shivering rate (RR 0.46; 95%CI 0.31, 0.67; P<0.0001; I2=0%) and mean final temperatures (MD 0.43; 95%CI 0.12, 0.75; I2=82%) also showed statistically significant differences between groups, favoring the irrigation with heated fluid. CONCLUSIONS: There was a decreased rate of hypothermia and shivering among patients undergoing PCNL with warm irrigation fluid. Mean final temperatures were also higher in the experimental group. As to blood loss, mean hemoglobin decrease showed no statistically significant difference between groups, prompting further investigation of the influence of Irrigation solution temperature on blood loss volume.

Intraoperative computed tomography for detection of residual stones in endourology procedures: systematic review and meta-analysis

ABSTRACT Background: Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures. Methods: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data. Results: A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI [3.61, 12.72]; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI [0.12,0.94]; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies. Conclusion: This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.