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OBJECTIVE: To compare the outcomes of retrograde flexible ureteroscopy (fURS) with retroperitoneal laparoscopic ureterolithotomy (RLU) for large proximal ureteric stones. PATIENTS AND METHODS: A prospective randomised trial was conducted from January 2018 through December 2022 including patients with impacted proximal ureteric stones of 15-25 mm. Patients underwent fURS or RLU. Primary outcome was the stone-free rate. Demographic data, stone features, and complications rates were also compared between groups. RESULTS: A total of 64 patients were enrolled, 32 in each group. The mean impacted stone time was similar between groups, as well as stone size (17 mm) and stone density (>1000 Hounsfield Units). The ureteric stone-free rates between the two groups (93.7% in fURS vs 96.8% in RLU; odds ratio [OR] 0.72, 95% confidence interval [CI] -1.72 to 3.17; P = 0.554), and overall success rates, which take into account residual fragments in the kidney (84.3% in fURS vs 93.7% in RLU; OR 1.02, 95% CI -0.69 to 2.74; P = 0.23), were similar. Operative time was also not statistically significantly different between groups (median 80 vs 82 min; P = 0.101). There was no difference in hospital length of stay. Retropulsion rate was higher with fURS (65.6% vs 3.1%; p < 0.001). Residual hydronephrosis (34.3% each group) and complication rates did no differ according to treatment. CONCLUSION: Flexible URS and RLU are both highly efficient and present low morbidity for large impacted proximal ureteric stone treatment. RLU is not superior to fURS.
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PURPOSE: High-quality evidence comparing supine to prone percutaneous nephrolithotomy (PCNL) for the treatment of complex stones is lacking. This study aimed to compare the outcomes of supine position (SUP) and prone position (PRO) PCNL. MATERIALS AND METHODS: A noninferior randomized controlled trial was performed according to the CONSORT (Consolidated Standards for Reporting Trials) criteria. The inclusion criteria were patients over 18 years of age with complex stones. SUP was performed in the Barts flank-free modified position. Except for positioning, all the surgical parameters were identical. The primary outcome was the difference in the success rate on the first postoperative day (POD1) between groups. The secondary outcome was the difference in the stone-free rate (SFR) on the 90th postoperative day (final SFR). A noninferiority margin of 15% was used. Demographic, operative, and safety variables were compared between the groups. Statistical significance was set at p <0.05. RESULTS: Overall, 112 patients were randomized and their demographic characteristics were comparable. The success rates on POD1 were similar (SUP: 62.5% vs PRO: 57.1%, p=0.563). The difference observed (-5.4%) was lower than the predefined limit. The final SFRs were also similar (SUP: 55.4% vs PRO: 50.0%, p=0.571). SUP had a shorter operative time (mean±SD 117.9±39.1 minutes vs 147.6±38.8 minutes, p <0.001) and PRO had a higher rate of Clavien ≥3 complications (14.3% vs 3.6%, p=0.045). CONCLUSIONS: Positioning during PCNL for complex kidney stones did not impact the success rates; consequently, both positions may be suitable. However, SUP might be associated with a lower high-grade complication rate.
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Cálculos Renais/cirurgia , Nefrolitotomia Percutânea/métodos , Posicionamento do Paciente , Cistoscopia , Feminino , Fluoroscopia , Humanos , Cálculos Renais/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Decúbito Ventral , Decúbito Dorsal , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: To assess the efficacy and safety of single-dose tranexamic acid on the blood transfusion rate and outcomes of patients with complex kidney stones undergoing percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: In a randomised, double-blinded, placebo-controlled trial, 192 patients with complex kidney stone (Guy's Stone Scores III-IV) were prospectively enrolled and randomised (1:1 ratio) to receive either one dose of tranexamic acid (1 g) or a placebo at the time of anaesthetic induction for PCNL. The primary outcome measure was the occurrence rate of perioperative blood transfusion. The secondary outcome measures included blood loss, operative time, stone-free rate (SFR), and complications. ClinicalTrials.gov identifier: NCT02966236. RESULTS: The overall risk of receiving a blood transfusion was reduced in the tranexamic acid group (2.2% vs 10.4%; relative risk, 0.21, 95% confidence interval [CI] 0.03-0.76, P = 0.033; number-needed-to-treat: 12). Patients randomised to the tranexamic acid group had a higher immediate and 3-month SFR compared with those in the placebo group (29% vs 14.7%, odds ratio [OR] 2.37, 95% CI 1.15-4.87, P = 0.019, and 46.2% vs 28.1%, OR 2.20, 95% CI 1.20-4.02, P = 0.011, respectively). Faster haemoglobin recovery occurred in patients in the tranexamic acid group (mean, 21.3 days; P = 0.001). No statistical differences were found in operative time and complications between groups. CONCLUSIONS: Tranexamic acid administration is safe and reduces the need for blood transfusion by five-times in patients with complex kidney stones undergoing PCNL. Moreover, tranexamic acid may contribute to better stone clearance rate and faster haemoglobin recovery without increasing complications. A single dose of tranexamic acid at the time of anaesthetic induction could be considered standard clinical practice for patients with complex kidney stones undergoing PCNL.
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Antifibrinolíticos/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Cálculos Renais/cirurgia , Nefrolitotomia Percutânea , Ácido Tranexâmico/uso terapêutico , Adolescente , Adulto , Idoso , Volume Sanguíneo , Método Duplo-Cego , Feminino , Hemoglobinas/metabolismo , Hemostasia Cirúrgica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Nefrolitotomia Percutânea/efeitos adversos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Adulto JovemRESUMO
ABSTRACT COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties nondirectly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.
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Humanos , Doenças Urológicas/terapia , Urologia/tendências , Pandemias , COVID-19RESUMO
COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.
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COVID-19 , Pandemias , Doenças Urológicas/terapia , Urologia/tendências , HumanosRESUMO
PURPOSE: To assess the complication and stone-free rates of PCNL in patients with spinal cord injury (SCI) and to evaluate whether this population should be assigned a Guy's stone score (GSS) of 4. METHODS: A case-control study was conducted, and electronic charts were reviewed to search for patients with SCI, bladder dysfunction, and kidney stones who had undergone PCNL. Control cases were randomly selected from among patients with complete staghorn calculus (GSS = 4). RESULTS: One hundred and seventeen patients were included. Patients with SCI had a significant shorter operative time (119 vs. 141 min; p = 0.018). There were no significant differences between the groups in terms of the patients' position, number of renal tracts, bleeding or transfusion rate; however, there was a significantly higher complication rate (23.1% vs. 7.8%; p = 0.009) and a longer hospital stay (5.8 vs. 3.1 days; p = 0.002) among patients with SCI. With regards to the stone-free rate in patients with different grades of GSS patients with SCI who had a GSS of 1 had a stone-free rate of 85.7%, while those with a GSS of 2, 3, or 4 had 50%, 50%, and 31.5%, respectively (p = 0.024). Only patients with a GSS of 4 in the SCI group had outcomes that were similar to those of control patients (31.5% vs. 31.6%). CONCLUSION: Patients with SCI should not be automatically assigned GSS 4. Stone-free rate is related to stone burden in these patients, although they do show a higher complication rate and a longer hospital stay than non-neurological patients.
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Nefrolitotomia Percutânea , Cálculos Coraliformes/cirurgia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Indução de Remissão , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Cálculos Coraliformes/etiologiaRESUMO
INTRODUCTION: Patients with bilateral kidney stones and burdened by large stones are challenging cases for endourologists. Simultaneous bilateral percutaneous nephrolithotomy (sbPCNL) is an option; however, it may be accompanied by important morbidity. An alternative is a staged PCNL, operating one side each time. Herein, we compare the impact of sbPCNL and staged PCNL on complication rates and renal function. METHODS: Patients who underwent sbPCNL or staged bilateral PCNL with a frame time of 6 months were searched in our prospectively collected kidney stone database. Groups were compared for age, gender, body mass index (BMI), comorbidities (classification by the American Society of Anesthesiology - ASA), stone size, Guy's score, stone-free status, renal function, blood loss, blood transfusion rate, complication rate, and length of hospital stay. RESULTS: Twenty-six patients and 52 kidney units were enrolled. The mean operative time was 134.7 min. Only 11.3% of cases had complications, all of them minor (Clavien ≤ 2). Overall, the stone-free rate was 61.50%. Comparing the groups, there was a significantly longer operative time in the sbPCNL group (172.5 vs. 126.3 min; p=0.016), as well as a higher transfusion rate (12.5% vs. 5.6%; p=0.036). There was no statistically significant difference in creatinine levels between the groups. Regarding the stone-free rate, there was a significantly higher proportion of patients in the staged PCNL group (64.9% vs. 43.8%; p=0.012). CONCLUSION: sbPCNL is a safe procedure; however, when compared to staged procedures it has a higher transfusion and lower stone-free rate.
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Cálculos Renais , Nefrolitotomia Percutânea , Nefrostomia Percutânea , Humanos , Cálculos Renais/cirurgia , Tempo de Internação , Nefrolitotomia Percutânea/efeitos adversos , Nefrostomia Percutânea/efeitos adversos , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
ABSTRACT Patients with staghorn renal stones are challenging cases, requiring careful preoperative evaluation and close follow-up to avoid stone recurrence. In this article we aim to discuss the main topics related to staghorn renal stones with focus on surgical approach. Most of staghorn renal stones are composed of struvite (magnesium ammonium phosphate) and are linked to urinary tract infection by urease-producing pathogens. Preoperative computed tomography scan and careful evaluation of all urine cultures made prior surgery are essential for a well-planning surgical approach and a right antibiotics choice. Gold standard surgical technique is the percutaneous nephrolithotomy (PCNL). In cases of impossible percutaneous renal access, anatrophic nephrolithotomy is an alternative. Shockwave lithotripsy and flexible ureteroscopy are useful tools to treat residual fragments that can be left after treatment of complete staghorn renal stone. PCNL can be performed in supine or prone position according to surgeon's experience. Tranexamic acid can be used to avoid bleeding. To check postoperative stone-free status, computed tomography is the most accurate imaging exam, but ultrasound combined to KUB is an option. Intra-operative high-resolution fluoroscopy and flexible nephroscopy have been described as an alternative for looking at residual fragments and save radiation exposure. The main goals of treatment are stone-free status, infection eradication, and recurrence prevention. Long-term or short-term antibiotic therapy is recommended and regular control imaging exams and urine culture should be done.