Patient's preferences: an unmet need by current urolithiasis guidelines: a systematic review.

INTRODUCTION: Shared decision making (SDM) in surgical specialties was demonstrated to diminish decisional regret, decisional anxiety and decisional conflict. Urolithiasis guidelines do not explicit patient preference to choose treatment. The aim of this review article was to perform a systematic evaluation of published evidence regarding SDM in urinary stone treatment. METHODS: A systematic review in accordance PRISMA checklist was conducted using the MEDLINE (PubMed) database. Inclusion criteria were studies that evaluated stone treatment preferences. Reviews, editorials, case reports and video abstracts were excluded. ROBUST checklist was used to assess quality of the studies. RESULTS: 188 articles were obtained. After applying the predefined selection criteria, seven articles were included for final analysis. Six out of seven studies were questionnaires that propose clinical scenarios and treatment alternatives. The last study was a patient preference trial. A general trend among included studies showed a patient preference towards the least invasive option (SWL over URS). The main reasons to choose one treatment over the other were stone-free rates, risk of complications and invasiveness. DISCUSSION: This review provides an overview of the patients' preferences towards stone treatment in small- and medium-sized stones. There was a clear preference towards the least invasive management strategy. The main reason was less invasiveness. This is opposed to the global trends of performing more ureteroscopies and less SWL. Physicians played a pivotal role in counselling patients. SDM should be encouraged and improved. The main limitation of this study is the characteristics of the included studies.

Is Guy's stone score useful for predicting outcomes in percutaneous nephrolithotomy?

INTRODUCTION: Percutaneous Nephrolithotomy (PCNL) is currently the treatment of choice in large kidney stones. Guy's stone score was developed to predict treatment outcomes. The aim of this study was to evaluate the relationship between Guy's score and outcomes in our institution. MATERIALS AND METHODS: The medical records of patients diagnosed with urolithiasis and treated by PCNL were retrospectively evaluated between January 2017 and December 2018. Analyzed data included: age, sex, Guy's score based on preoperative findings, transfusion, stone-free rate and requirement of auxiliary procedures. Chi-square test was used for the comparison of proportions. Odds ratios (OR) with confidence intervals (CIs) of 95% were calculated by logistic regression. RESULTS: A total of 386 patients, 53.89% female, mean age of 45.59 ±â€¯15 years were analyzed. Guy's score was as follows: 112 patients (29.04%) were classified as Guy I, 92 patients (23.82%) as Guy II, 94 patients (24.34%) as Guy III, and 88 patients (22.80%) as Guy IV. There were no differences between groups in terms of blood transfusions. Stone-free rate was 96.43% (n = 108) for patients Guy I; 84.78% (n = 72) for Guy II; 76.59% (n = 72) for Guy III and 50% (n = 44) for Guy IV categories (p < 0.0001). Taking as a reference Guy I group, the OR to require new treatment for residual stones were: Guy II 4.85 (CI = 0.95 to 24.60, P = 0.05) to Guy III 8.25 (CI = 1.73 to 39.44, P = 0.008) and Guy IV 27 (CI = 5.84 to 124.70; p < 0.0001). CONCLUSION: There was a statistically significant association between Guy's Score and stone-free rates following PCNL. Guy's score was useful to predict results of PCNL in our group.

Case Report: Mini-endoscopic combined intrarenal surgery in an en-bloc kidney transplant.

BACKGROUND: Overall incidence of stones in kidney transplant recipients is 1%. En-bloc kidney transplant is a rare anatomical condition in which kidney stones treatment can be extremely difficult to treat. As far as we know, no cases of staghorn calculi in en-bloc kidney transplant have been published so far. CASE PRESENTATION: A 27-year-old woman presented to the Emergency Department because of asthenia, adynamia and weight loss associated with lower urinary tract symptoms and subfebrile temperature. Ten years before, she had undergone an en-bloc kidney transplant because of end-stage renal disease secondary to perinatal asphyxia syndrome. One kidney was implanted capo-volta in the right iliac fossa and the other one in the right flank. NCCT scan showed incomplete staghorn calculi in the iliac fossa transplanted kidney. Besides, severe dilation of the native and the right flank transplanted kidney, due to two ureteral stones of 6 and 7 mm impacted in the uretero-ureteral anastomosis, was found. After hospital admission and under ceftriaxone prophylaxis, an attempt to perform primary RIRS following our COVID protocol was carried out. Nevertheless, we ended up placing a JJ stent because once the guidewire passed through the ureteral stones, purulent material came out from the ureteral orifice. She stayed 9 days in-hospital for management of postobstructive polyuria and was discharged with oral antibiotics. Three weeks afterward, we removed the stent and performed flexible ureteroscopy and holmium laser lithotripsy of the ureteral stones. In the same procedure, we performed Mini-ECIRS (21 French) previous ultrasound-guided upper pole puncture. Postoperative NCCT scan showed neither residual fragments nor operative complications. CONCLUSION: This is the first clinical case reporting Mini-ECIRS in a patient with an en-bloc kidney transplant. This endourological approach seems to be a feasible, safe and effective approach to treat stones in this anatomically challenging condition.

Is extracorporeal shockwave lithotripsy (SWL) still suitable for >1.5 cm intrarenal stones? Data analysis of 1902 SWLs.

PURPOSE: According to the American Urological Association and European Association of Urology guidelines, shockwave lithotripsy (SWL) is the least-invasive treatment option for kidney stones smaller than 2 cm. However, it is well known that SWL stone-free rates (SFR) decline as stone size increases. We sought to evaluate whether the size limit of 1.5 cm could be a better predictor of success after a single SWL session than current recommendations. METHODS: Data from an SWL-dedicated center were prospectively scrutinized according to stone locations and sizes. Information on patients' demography, lithotripsy parameters, and outcomes was evaluated by multivariate analysis among 1902 SWLs. RESULTS: The overall SFR was 70.8% (1347/1902). SFRs according to stone size were <1 cm: 73.8% (825/1118), 1-1.5 cm: 70.4% (401/569) and >1.5 cm: 56.2% (121/215); and according to calculi location were lower pole (LP) 64.4% (398/618), mid pole 73.8% (339/459), upper pole 73.8% (273/370) and renal pelvis 74.1% (337/455). Multivariate analysis revealed better SFR independent better SFR in <1.5 cm (p < 0.01), and non-LP stones (p < 0.01). CONCLUSION: SWL is an effective treatment modality for kidney stones. The single session reached up to 74.8% SFRs (range 70.8%-74.8%) when indicated for intrarenal non LP stones smaller than 1.5 cm. Patients with stones >1.5 cm or >1 cm located in the LP should be counseled on the lower SFRs after a single SWL session.

Is a differential diagnosis necessary in a patient with ureteritis cystica?

Ureteritis cystica is a rare urological disease with an undefined etiology. Despite the benign behavior, the differential diagnosis should be investigated, as other conditions the cause filling defects in the ureters may occur. We present a rare case of a patient with ureteritis cystica whose differential diagnosis was satisfactory.

Arteriocaliceal Fistula: A Life-Threatening Condition After Retrograde Intrarenal Surgery.

Background: Retrograde intrarenal surgery (RIRS) has emerged as a viable and safe option for renal stones <2 cm. Because of its high efficiency and relative safety, experienced endourologists have applied it to even larger stones. We present a case of arteriocaliceal fistula, which is a rare postoperative complication of RIRS. Case Presentation: A 52-year-old man with a rich history of endourologic procedures and extracorporeal shockwave lithotripsy caused by inferior caliceal calculi was subjected to RIRS. This was complicated by transient intraoperative hemorrhage, followed by recurrent hematuria and clot retention several days postoperatively. Renal arteriography revealed the presence of an arteriocaliceal fistula. This was completely resolved with selective arterial embolization. Conclusion: This case highlights that early detection and timely intervention are crucial to avoid serious consequences of post-RIRS hemorrhage resulting from arteriocaliceal fistula.

Endoscopic Treatment of Fibroepithelial Polyp of the Ureter: Case Report.

Background: Fibroepithelial polyp of the ureter is a very rare benign tumor of the urinary tract that can present complications as urinary tract infection, hematuria, or urinary retention. Its incidence has increased in recent years. Its recognition and proper management are important to avoid invasive surgeries. Case Presentation: We present the case of a 24-year-old Latin pregnant woman with gross hematuria, right flank pain, and a bladder tumor as seen on a pelvic ultrasonography. Cystoscopy and MRI showed a right ureteral tumor that protruded through the ureteral meatus. Endoscopic resection using a holmium:YAG laser was performed during the second trimester of pregnancy. A ureteral tumor of 6.5 cm was completely resected. Histopathology showed morphological findings compatible with a fibroepithelial ureteral polyp. The postoperative evolution was satisfactory with no complications or recurrences to date. Conclusion: Fibroepithelial polyp of the ureter is a benign tumor that can be present in any of the ureter's segments. It usually affects people between 20 and 40 years. Endoscopic resection with holmium laser has become the preferred surgical treatment during the last time. It is associated with the advantages of a minimal invasive technique and a short period of convalescence.

Ureteroscopic Excision of Distal Ureteral Endometriosis.

Background: Endometriosis is the presence of endometrial tissue outside the uterus. Involvement of the urinary tract is uncommon; however, ureteral endometriosis (UE) is even more unusual. Most patients are clinically asymptomatic, which may lead to silent renal loss secondary to obstructive urinary tract endometriosis. Only a few cases of intrinsic UE treated by endoscopic excision have been reported. Case Presentation: We report a case of a 40-year-old woman with chronic right flank pain, with a right distal ureteral obstructive lesion. Ureteroscopy identified a lesion and ureteroscopic resection was performed. Histologic analysis revealed intrinsic UE. Conclusion: Ureteroscopic excision of intrinsic UE is a feasible option for treatment as we have shown in this case.

Ureteritis cystica and ureteral polyp-case report.

Ureteritis cystica associated with ureteral polyp is a rare urology condition and may be related to ureteral obstruction, therefore needs to be treated accordingly. It may be accompanied by other ureteral pathologies and definitive diagnosis requires biopsy or resection of the lesions. Few similar cases have been described in the literature. We report a case of a patient with simultaneous ureteritis cystica and a benign ureteral polyp that had a satisfactory surgical approach.

Outcomes of more than 1 000 percutaneous nephrolithotomies and validation of Guy's stone score.

OBJECTIVE: To present the experience with percutaneous nephrolithotomy (PCNL) at a high-volume Brazilian centre and to evaluate Guy's stone score (GSS) as a predictor of success and complications in PCNL. PATIENTS AND METHODS: We prospectively evaluated patients who underwent PCNL between June 2011 and October 2016. Indications for PCNL included renal stones >2 cm in size and stones <2 cm in size in which first-line techniques had failed. All patients underwent a complete preoperative evaluation, including non-contrast-enhanced abdominal computed tomography (CT). Stone complexity was assessed using GSS. Success was defined as the absence of fragments >2 mm on CT on postoperative day 1. Complications were classified according to the Clavien grade. RESULTS: A total of 1 066 PCNLs were performed on 891 patients. In all, 20.2% were classified as GSS1, 27.4% as GSS2, 35.0% as GSS3, and 17.4% as GSS4. The mean operating time was 108.44 min, and the mean fluoroscopy time was 13.57 min. The overall immediate success rate based on postoperative day 1 CT was 43.8%. Complications occurred in 14.9% of cases, and the mean length of hospital stay was 54.55 h. Stratifying patients according to GSS, success rate was inversely proportional to the calculus complexity: GSS1: 87.9%; GSS2: 62.1%; GSS3: 44.0%; and GSS4: 24.3% (P < 0.001). Higher GSS categories were significantly correlated with the number of puncture tracts (P < 0.001), operating time (P < 0.001), fluoroscopy time (P < 0.001), blood transfusion rate (P < 0.001), complications (P < 0.001) and length of stay (P < 0.001). CONCLUSION: In a high-volume centre, PCNL was a reliable surgical technique, with low morbidity and short hospital stay. GSS was confirmed to be a very useful tool for predicting the outcomes of PCNL, and its use should be encouraged.

Update on ureteroscopy instrumentation.

The authors present an objective review of what is new in endourology instrumentation, based on up-to-date scientific data gathered from meetings, state-of-art lectures and current literature. The main scope of this review is to highlight the most recommended device options for each step of an ureteroscopy, in order to offer best care to patients.

Development of a computer assisted gantry system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy

PURPOSE: To design a simple, cost-effective system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The design consists of a low-cost, light-weight, portable mechanical gantry with a needle guiding device. Using C-arm fluoroscopy, two images of the contrast-filled renal collecting system are obtained: at 0-degrees (perpendicular to the kidney) and 20-degrees. These images are relayed to a laptop computer containing the software and graphic user interface for selecting the targeted calyx. The software provides numerical settings for the 3 axes of the gantry, which are used to position the needle guiding device. The needle is advanced through the guide to the depth calculated by the software, thus puncturing the targeted calyx. Testing of the system was performed on 2 target types: 1) radiolucent plastic tubes the approximate size of a renal calyx (5 or 10 mm in diameter, 30 mm in length); and 2) foam-occluded, contrast-filled porcine kidneys. RESULTS: Tests using target type 1 with 10 mm diameter (n = 14) and 5 mm diameter (n = 7) tubes resulted in a 100 percent targeting success rate, with a mean procedure duration of 10 minutes. Tests using target type 2 (n = 2) were both successful, with accurate puncturing of the selected renal calyx, and a mean procedure duration of 15 minutes. CONCLUSIONS: The mechanical gantry system described in this paper is low-cost, portable, light-weight, and simple to set up and operate. C-arm fluoroscopy is limited to two images, thus reducing radiation exposure significantly. Testing of the system showed an extremely high degree of accuracy in gaining precise access to a targeted renal calyx.

Endourological Management of Forgotten Encrusted Ureteral Stents

PURPOSE: To present our experience and discuss the various endourological approaches for treating forgotten encrusted ureteral stents associated with stone formation. MATERIALS AND METHODS: From July 2006 to December 2008, 14 patients (11 men and 3 women) with encrusted ureteral stents were analyzed. The average indwelling time of the stent was 4.9 years (range 1 to 12). Plain-film radiography was used to evaluate encrustation, stone burden, and fragmentation of the stents. Intravenous urogram and a Tc99m diethylene triamine penta acetic-acid renogram was used to assess renal function. RESULTS: In seven patients, the entire stent was encrusted, in three patients the encrustation was confined to the ureteral and lower coil part of the stent, two patients had encrustation of the lower coil, and minimal encrustation was observed in two patients. Percutaneous nephrolithotomy was performed in 5 cases and retrograde ureteroscopy with intra-corporeal lithotripsy in 9 patients. Cystolithotripsy was used to manage the distal coil of the encrusted stent in eight patients. Simple cystoscopic removal of the stents with minimal encrustation was carried-out in two cases. Looposcopy and removal of the stent was performed in one patient with an ileal conduit and retained stent. Only one patient required open surgical removal of the stent. Thirteen out of 14 patients were rendered stone and stent free in one session. All except two stents were removed intact and stone analysis of encrustation and calcification revealed calcium oxalate and calcium phosphate in the majority of the cases. CONCLUSION: Endourological management of forgotten encrusted stents is highly successful and often avoids the need for open surgical techniques.

Experiencia en el tratamiento endoscópico de la litiasis ureteral / Experience in the endoscopic treatment of ureteral stones

Objetivos: La endourología con procedimientos menos invasivos ha sustituido la cirugía convencional en el manejo de algunas patologías, con una baja morbilidad y altos índices de resolución. El progreso de la ureteroscopia con disminución del calibre del instrumental y mejoría de los sistemas ópticos y accesorios han permitido mejor acceso y visión del tracto urinario, disminuyendo los índices de complicaciones. Material y Método: análisis retrospectivo de nuestra experiencia en el abordaje ureteroscópico de lalitiasis ureteral durante el período febrero 2004 - diciembre 2005. Se definió el éxito de la cirugía según la fragmentación completa de la litiasis y la desobstrucción respectiva. Resultados: Se realizaron 50 cirugías, distribuidas en rango etareo 18-83 años, 28 pacientes de sexo masculino y 22 de sexo femenino. El tamaño litiásico abordado varió de 0,5 -2 cm. Se logró la fragmentación completa del cálculo en 92 por ciento de los casos, en 2 pacientes se logró fragmentación parcial y en otros 2 no se logró el acceso por migración de la litiasis. Se describen como complicaciones las inherentes al procedimiento, hematuria, perforación ureteral localizada y 1 caso de falsa vía. Conclusiones: La ureterolitotomia endoscópica resulta un procedimiento seguro y eficaz en la resolución de la litiasis ureteral distal con baja morbilidad asociada, la disponibilidad de la litotripsia intracorporea permite mayor flexibilidad en la indicación de esta técnica. Constituye nuestra modalidad de elección, considerando la poca disponibilidad de litotripsia extracorpórea.

Introduction: Endourology has replaced conventional surgery in management of several urological diseases, with a low morbidity and excellent results. The progress of ureteroscopy with reduced and improved instruments and more advanced optical systems have allowed better access and vision of the urinary tract, reducing the rates of complications. Material and Methods: Retrospective analysis of our experience in the ureteroscopic management of ureteral stones during the period from February 2004 - December 2005. Succesful surgery was define We define as successful according to both the fragmentation of the stones and resolution of obstruction. Results: Fifty surgeries were performed in patients with an age range 18-83 years. Male to female ratio was 3/2. Stone tone size ranged from 0.5 to 2 cm. Complete fragmentation was achieved in 92 percent of the cases, 2 patients achieved partial fragmentation and in one case we experienced migration of stone and the procedure was not completed. The complications rate observed I the series was low. Conclusions: Endourological management of ureteral stones is safe and effective for the resolution of distal ureteral calculi with low morbidity. Availability of intracorporeal lithotripsy allows greater flexibility in the indication of this technique. In our hands this woud be the technique of choice.