International Alliance of Urolithiasis (IAU) guideline on staghorn calculi management.

BACKGROUND: The stone burden based management strategy reported in the guidelines published by different associations is well known for a long time. Staghorn calculi, representing the largest burden and most complex stones, is one of the most challenging cases to practicing urologists in clinical practice. The International Alliance of Urolithiasis (IAU) has released a series of guidelines on the management of urolithiasis. PURPOSE: To develop a series of recommendations for the contemporary management management of staghorn calculi and to provide a clinical framework for urologists treating patients with these complex stones. METHODS: A comprehensive literature search for articles published in English between 01/01/1976 and 31/12/2022 in the PubMed, OVID, Embase and Medline database is performed. A series of recommendations are developed and individually graded following the review of literature and panel discussion. RESULTS: The definition, pathogenesis, pathophysiology, preoperative evaluation, intraoperative treatment strategies and procedural advice, early postoperative management, follow up and prevention of stone recurrence are summarized in the present document. CONCLUSION: A series of recommendations regarding the management of staghorn calculi, along with related commentary and supporting documentation offered in the present guideline is intended to provide a clinical framework for the practicing urologists in the management of staghorn calculi.

High-frequency shock wave lithotripsy: stone comminution and evaluation of renal parenchyma injury in a porcine ex-vivo model.

BACKGROUND: The electrohydraulic high-frequency shock wave (Storz Medical, Taegerwilen, Switzerland) is a new way to create small fragments with frequencies up to 100 Hertz (Hz). This study evaluated the efficacy and safety of this method in a stone and porcine model. MATERIALS AND METHODS: BEGO stones were put in a condom in a specifically designed fixture treated with different modulations to see stone comminution. Standardized ex vivo porcine model with perfused kidneys with 26 upper and lower poles of 15 kidneys was treated with the following modulations: voltage 16-24 kV, capacitor 12 nF and frequency up to 100 Hz. 2000-20,000 shock waves were applied to each pole. The kidneys were perfused with barium sulfate solution (BaSO4) and x-ray was performed to quantify the lesions using pixel volumetry. RESULTS: There was no correlation between the number of shock waves and the powdering degree or the applied Energy and the grade of pulverization in the stone model. Regarding the perfused kidney model, the number of shock waves, applied voltage and frequency had no direct correlation with the occurrence of parenchymal lesions The detected lesions of the renal parenchyma were minimal, technical parameters had no significant impact and the lesions did not differ from the results of former experiments using 1-1.5 Hz in the same model. CONCLUSIONS: High-frequency shock wave lithotripsy can produce small stone fragments to pass in a very short time. The injury to the renal parenchyma is comparable to the results of the conventional SWL using 1-1.5 Hz.

Percutaneous nephrolithotomy - the puncture.

OBJECTIVE: To determine what importance is given to the puncture and assistive technologies in percutaneous nephrolithotomy (PNL) in the current urological literature. METHODS: PubMed was searched for English publications and reviews for the keywords: 'percutaneous nephrolithotomy', 'percutaneous nephrostomy', 'puncture'. The search was limited to the last 5 years, January 2016 until February 2021. Based on 183 abstracts, 121 publications were selected, read, and reviewed. References, older or seminal papers were read and cited if they contributed to a better understanding. A total of 198 references form the basis of this narrative review. RESULTS: The puncture is frequently referred to as the most crucial part of PNL. In contrast, the influence of the puncture on the failure rate of PNL and the specific puncture-related complications seems to be low in the single-digit percentage range. However, there are no universally accepted definitions and standards measuring the quality of puncture. Consequently, the impact of the puncture on general PNL complications, on stone scores predicting success rates and on learning curves evaluating surgeons' performance have not been systematically studied. Assistive technologies rely on fluoroscopy and ultrasonography, the latter of which is becoming the preferred imaging modality for monitoring the entire procedure. Needle bending, a problem relevant to all puncture techniques, is not addressed in the urological literature. CONCLUSIONS: The importance attached to puncture in PNL in the current urological literature is subjectively high but objectively low. Some basics of puncture are not well understood in urology. Disciplines other than urology are more actively involved in the development of puncture techniques.

[Looking back on 50 years of stone treatment]. / Rückblick auf 50 Jahre Steintherapie.

Urolithiasis is an urologist's daily business. This article provides an overview of the developments in the management of urinary stone disease since the 1970s. While conventional KUB X-rays and intravenous pyelography were standard imaging procedures in the past, computed tomography is the first choice today. Conservative treatments such as medical expulsive therapy were established to facilitate ureteral stone passage, but have come into discussion in the past few years. Fifty years ago, open stone surgery was the standard procedure to access renal stones. This has been superseded by minimally-invasive procedures ranging from percutaneous nephrolithotomy (PCNL) to extracorporeal shock-wave lithotripsy (ESWL) and ureteroscopy (URS), which is today's standard for most upper urinary tract stones. It would have been desirable if such enormous efforts and progress had been made in the evaluation of stone pathogenesis and the improvement of preventative measures. Unfortunately, the knowledge on stone formation has hardly improved compared to 1970.

Intracorporeal lithotripsy.

Since the introduction of ESWL, PNL and URS during the early 1980s the application rate of ESWL has declined while those of PNL and URS have increased. This is mainly due to the facts that instruments and techniques for Intracorporeal Lithotripsy (IL) have made a continuous progress. This review shows that today an array of options for IL within the entire urinary tract is available to treat stones in a perfect minimal invasive way. At the same time further improvements of IL are already visible.

The economics of stone disease.

The rising prevalence of kidney stone disease is associated with significant costs to healthcare systems worldwide. This is in part due to direct procedural and medical management costs, as well as indirect costs to health systems, patients, and families. A number of manuscripts evaulating the economics of stone disease have been published since the 2008s International Consultation on Stone Disease. These highlight costs associated with stone disease, including acute management, surgical management, and medical management. This work hopes to highlight optimization in care by reducing inefficient treatments and maximizing cost-efficient preventative strategies.

Heart of Darkness.

Significant literature has an impact on the reader. Reading the novella Heart of Darkness by Joseph Conrad as a young boy rose emotions comparable to those I felt when losing a patient after percutaneous nephrolithotomy (PCNL) as a grown up. The case of a 37-year-old woman with bilateral staghorn and a fatal outcome after PCNL is presented and alternatives are discussed.

Positioning for percutaneous nephrolithotomy.

PURPOSE OF THE REVIEW: To highlight the progressive evolution of the issue of patient positioning for percutaneous nephrolithotomy (PNL), explain the history of the prone and supine positions, report respective advantages and drawbacks, critically interpret the past and current literature supporting such arguments, identify the best candidates for each position, and reflect on the future evolution of the two approaches. RECENT FINDINGS: Positioning for PNL has become a matter of debate during the last decade. The traditional prone PNL position - most widely performed with good success and few complications, and exhibiting essentially no limits except for the treatment of pelvic kidneys - is nowadays flanked mainly by the supine and supine-modified positions, equally effective and probably safer from an anesthesiological point of view. Of course, both approaches have a number of advantages and drawbacks, accurately reported and critically sieved. SUMMARY: The current challenge for endourologists is to be able to perform PNL in both prone and supine positions to perfectly tailor the procedure on any patient with any stone burden, including increasingly challenging cases and medically high-risk patients, according to the patient's best interest. Intensive training and experience is especially needed for supine PNL, still less popular and underperformed worldwide. VIDEO ABSTRACT: http://links.lww.com/COU/A8.

Extracorporeal shock wave lithotripsy: An opinion on its future.

The development of miniaturized nephroscopes which allow one-stage stone clearance with minimal morbidity has brought the role of shock wave lithotripsy (SWL) in stone management into question. Design innovations in SWL machines over the last decade have attempted to address this problem. We reviewed the recent literature on SWL using a MEDLINE/PUBMED research. For commenting on the future of SWL, we took the subjective opinion of two senior urologists, one mid-level expert, and an upcoming junior fellow. There have been a number of recent changes in lithotripter design and techniques. This includes the use of multiple focus machines and improved coupling designs. Additional changes involve better localization real-time monitoring. The main goal of stone treatment today seems to be to get rid of the stone in one session rather than being treated multiple times non-invasively. Stone treatment in the future will be individualized by genetic screening of stone formers, using improved SWL devices for small stones only. However, there is still no consensus about the design of the ideal lithotripter. Innovative concepts such as emergency SWL for ureteric stones may be implemented in clinical routine.

The past, present and future of minimally invasive therapy in urology: a review and speculative outlook.

INTRODUCTION: Twenty-five years of SMIT represents an important date. In this article we want to elaborate the development of minimally invasive surgery in urology during the last three decades and try to look 25 years ahead. MATERIAL AND METHODS: As classical scenarios to demonstrate the changes which have revolutionized surgical treatment in urology, we have selected the management of urolithiasis, renal tumour, and localized prostate cancer. This was based on personal experience and a review of the recent literature on MIS in Urology on a MEDLINE/PUBMED research. For the outlook to the future, we have taken the expertise of two senior urologists, middle-aged experts, and upcoming junior fellows, respectively. RESULTS: Management of urolithiasis has been revolutionized with the introduction of non-invasive extracorporeal shock wave lithotripsy (ESWL) and minimally invasive endourology in the mid-eighties of the last century obviating open surgery. This trend has been continued with perfection and miniaturization of endourologic armamentarium rather than significantly improving ESWL. The main goal is now to get rid of the stone in one session rather in multiple non-invasive treatment sessions. Stone treatment 25 years from today will be individualized by genetic screening of stone formers, using improved ESWL-devices for small stones and transuretereal or percutaneous stone retrieval for larger and multiple stones. Management of renal tumours has also changed significantly over the last 25 years. In 1988, open radical nephrectomy was the only therapeutic option for renal masses. Nowadays, tumour size determines the choice of treatment. Tumours >4 cm are usually treated by laparoscopic nephrectomy, smaller tumours, however, can be treated either by open, laparoscopic or robot-assisted partial nephrectomy. For patients with high co-morbidity focal tumour ablation or even active surveillance represents a viable option. In 25 years, imaging of tumours will further support early diagnosis, but will also be able to determine the pathohistological pattern of the tumour to decide whether the patient requires removal, ablation or active surveillance. Management of localized prostate cancer underwent significant changes as well. 25 years ago open retropubic nerve-sparing radical prostatectomy was introduced as the optimal option for effective treatment of the cancer providing minimal side-effects. Basically, the same operation is performed today, but with robot-assisted laparoscopic techniques providing 7-DOF instruments, 3D-vision and tenfold magnification and enabling the surgeon to work in a sitting position at the console. In 25 years, prostate cancer may be managed in most cases by focal therapy and/or genetically targeting therapy. Only a few patients may still require robot-assisted removal of the entire gland. DISCUSSION: There has been a dramatic change in the management of the most frequent urologic diseases almost completely replacing open surgery by minimally invasive techniques. This was promoted by technical realisation of physical principles (shock waves, optical resolution, master-slave system) used outside of medicine. The future of medicine may lie in translational approaches individualizing the management based on genetic information and focalizing the treatment by further improvement of imaging technology.

Percutaneous nephrolithotomy and chronic kidney disease: results from the CROES PCNL Global Study.

PURPOSE: We compared the characteristics and outcomes of patients treated with percutaneous nephrolithotomy in the CROES (Clinical Research Office of the Endourological Society) Global Study according to preoperative renal function. MATERIALS AND METHODS: Prospective data on consecutive patients treated with percutaneous nephrolithotomy in a 1-year period were collected from 96 participating centers. The glomerular filtration rate was estimated using the Modification of Diet in Renal Disease formula based on preoperative serum creatinine measurement. Patients were divided into 3 groups by glomerular filtration rate, including chronic kidney disease stages 0/I/II-greater than 60, stage III-30 to 59 and stages IV/V-less than 30 ml/minute/1.73 m(2). Patient characteristics, operative characteristics, outcomes and morbidity were assessed. RESULTS: Estimated glomerular filtration rate data were available on 5,644 patients, including 4,436 with chronic kidney disease stages 0/I/II, 994 with stage III and 214 with stages IV/V. A clinically significant minority of patients with nephrolithiasis presented with severe chronic kidney disease. A greater number of patients with stages IV/V previously underwent percutaneous nephrolithotomy, ureteroscopy or nephrostomy and had positive urine cultures than less severely affected patients, consistent with the higher incidence of staghorn stones in these patients. Patients with chronic kidney disease stages IV/V had statistically significantly worse postoperative outcomes than those in the other chronic kidney disease groups. CONCLUSIONS: Poor renal function negatively impacts the post-percutaneous nephrolithotomy outcome. By more aggressive removal of kidney stones, particularly staghorn stones, at first presentation and more vigilantly attempting to prevent recurrence through infection control, pharmacological or other interventions, the progression of chronic kidney disease due to nephrolithiasis may be mitigated.

The clinical research office of the endourological society audit committee.

The Clinical Research Office of the Endourological Society (CROES) conducts large-scale, international, multicenter clinical trials in the field of endourology. One of the major challenges that these trials pose is to ensure that data collected remotely and online within a very short time frame are valid and reliable. This editorial describes a formal process for auditing the data by the CROES Audit Committee. The audit process presented is largely based on an automatic scoring system, which takes into consideration several parameters to determine the quality of the data and of the participating institution. This process is dynamic in nature and offers live monitoring of both patient data and study centers.

The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: tract dilation comparisons in 5537 patients.

PURPOSE: The study focused on the use of balloon or telescopic/serial dilation methods in percutaneous nephrolithotomy (PCNL) in the Global PCNL Study. PATIENTS AND METHODS: Centers worldwide provided data from consecutive patients who were treated with PCNL during a 1-year period. Tract dilation was performed using a balloon or telescopic/serial dilator. Patient characteristics, perioperative complications, and treatment outcomes were assessed by the treating physician. Postoperative complications were graded according to the modified Clavien grading system. RESULTS: A total of 5537 eligible patients were entered in the database from November 2007 to December 2009, including 2277 (41.1%) who received balloon dilation and 3260 (58.9%) who received telescopic/serial dilation. The predominant method used was telescopic/serial dilation in Asia (94.7%) and South America (98.0%), and balloon dilation in North America (82.6%). In Europe, the rates of balloon (50.7%) and telescopic/serial (49.3%) dilation procedures were similar. The rates of bleeding (9.4% vs. 6.7%), blood transfusions (7.0% vs. 4.9%), and drop in mean hematocrit level (4.5% vs. 2.5%) were higher in the balloon vs. telescopic/serial dilator group. Clavien scores II and IIIA were slightly in favor of the telescopic/serial dilator group. Median operative time was longer in the balloon dilation group (94.0 min vs. 60.0 min). CONCLUSIONS: The Global PCNL Study has identified differences in the method of dilation used between centers in Asia, Europe, and the United States. In the balloon dilation group, a total longer operative time and higher bleeding and transfusion rates were observed. The differences in outcome may be influenced by patient heterogeneity, including previous anticoagulation therapy or surgical procedures, in addition to the number of stones treated and rate of staghorn calculi, which were all higher in the balloon group.

Prolonged cold ischemia time for laparoscopic partial nephrectomy with a new cooling material: Freka-Gelice--a comparison of four cooling methods.

BACKGROUND AND PURPOSE: It is well known that hypothermia protects renal tissue from ischemic damage. So far, no standardized cooling method for laparoscopic surgery has been established. The traditionally used cooling method during open partial nephrectomy (OPN) is crushed ice applied around the kidney; for laparoscopic use, transarterial and transureteral perfusion cooling are described. We compared these three cooling methods with Freka-Gelice (FG), a new gel-like cooling material, and present our initial preliminary results in an ex-vivo porcine model. MATERIALS AND METHODS: To prove cooling effectiveness, FG was compared with superficial crushed ice (NaCl-ice), with transureteral perfusion (TUP), and with transarterial perfusion (TAP) cooling in ex-vivo porcine kidneys. The temperature decrease over 120 minutes and practical application were evaluated. RESULTS: No significant difference was found for the mean value distribution at different time points for NaCl-ice and FG (P = 0.18). TUP and TAP showed insufficient temperature decrease. Mean temperatures for NaCl-ice and FG were 4.75 degrees C and 7.02 degrees C at 30 minutes, 0.72 degrees C and 2.47 degrees C at 60 minutes, and -0.19 degrees C and 2.35 degrees C at 120 minutes, respectively. FG was easy to use because of its gel-like consistence. CONCLUSION: TUP and TAP did not provide a fast and sufficient temperature decrease for renal hypothermia in this ex-vivo model. FG shows sufficient cooling qualities comparable with conventionally used NaCl-ice. Because of its gel-like consistence, FG can be used for laparoscopic partial nephrectomy, because insertion through a trocar is possible.