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.

Worldwide trends of practice and intervention in paediatric endourology: comparison of European versus Non-European responses.

Introduction: The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise. Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients. Material and methods: The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia. The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM). Results: 221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries). In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice. Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists. 12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists. Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)]. Conclusions: Treatment of paediatric stones can vary according to country and legislations. Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular. In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.

International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy.

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Diferencias entre el Urocultivo Previo y el cultivo del Catéter doble J. Implicancias clínicas / DIFFERENCES BETWEEN PREVIOUS URINE CULTURE AND DOUBLE J CATHETER CULTURE. CLINICAL IMPLICATIONS

Las infecciones urinarias complicadas, dentro de las cuales se encuentran las asociadas a catéteres, son un hallazgo frecuente de la práctica clínica. Las complicaciones infecciosas después de los procedimientos urológicos son una fuente importante de morbimortalidad y consumen múltiples recursos sanitarios. La colonización bacteriana en el catéter ureteral juega un papel esencial en la patogénesis de la infección, y el uso de profilaxis antimicrobiana en urología es controvertido. El objetivo de nuestro trabajo fue evaluar la utilidad de la profilaxis antibiótica en la extracción del catéter doble J

Complicated urinary infections, among which are those associated with catheters, are a frequent finding in clinical practice. Infectious complications after urological procedures are an important source of morbidity and mortality and consume multiple healthcare resources. Bacterial colonization in the ureteral catheter plays an essential role in the pathogenesis of infection, and the use of antimicrobial prophylaxis in urology is controversial. Te objective of our work was to evaluate the usefulness of antibiotic prophylaxis in the extraction of the double J catheter

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Retrograde Intrarenal Surgery for the Management of Renal Stones.

BACKGROUND: Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide. OBJECTIVE: To develop recommendations for RIRS on the basis of existing data and expert consensus. DESIGN, SETTING, AND PARTICIPANTS: A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%. RESULTS AND LIMITATIONS: The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed. CONCLUSIONS: The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting. PATIENT SUMMARY: An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.

European Association of Urology Section of Urolithiasis and International Alliance of Urolithiasis Joint Consensus on Percutaneous Nephrolithotomy.

CONTEXT: Although percutaneous nephrolithotomy (PCNL) has been performed for decades and has gone through many refinements, there are still concerns regarding its more widespread utilization because of the long learning curve and the potential risk of severe complications. Many technical details are not included in the guidelines because of their nature and research protocol. OBJECTIVE: To achieve an expert consensus viewpoint on PCNL indications, preoperative patient preparation, surgical strategy, management and prevention of severe complications, postoperative management, and follow-up. EVIDENCE ACQUISITION: An international panel of experts from the Urolithiasis Section of the European Association of Urology, International Alliance of Urolithiasis, and other urology associations was enrolled, and a prospectively conducted study, incorporating literature review, discussion on research gaps (RGs), and questionnaires and following data analysis, was performed to reach a consensus on PCNL. EVIDENCE SYNTHESIS: The expert panel consisted of 36 specialists in PCNL from 20 countries all around the world. A consensus on PCNL was developed. The expert panel was not as large as expected, and the discussion on RGs did not bring in more supportive evidence in the present consensus. CONCLUSIONS: Adequate preoperative preparation, especially elimination of urinary tract infection prior to PCNL, accurate puncture with guidance of fluoroscopy and/or ultrasonography or a combination, keeping a low intrarenal pressure, and shortening of operation time during PCNL are important technical requirements to ensure safety and efficiency in PCNL. PATIENT SUMMARY: Percutaneous nephrolithotomy (PCNL) has been a well-established procedure for the management of upper urinary tract stones. However, according to an expert panel consensus, core technical aspects, as well as the urologist's experience, are critical to the safety and effectiveness of PCNL.

Simultaneous Ureteral and Renal Foreign Bodies.

Clinical presentation of patients with foreign bodies is highly variable. We received a 55-year-old female patient with fever and right flank pain. She was treated previously for kidney stones by percutaneous nephrolithtomy with partial resolution, requiring renal embolization during this procedure because of bleeding. CT evidenced metallic density images localized in kidney and ureter, associated with kidney stones located in lower calix. Semirigid ureteroscopy and retrograde intrarenal surgery were performed, revealing the presence of foreign bodies in both localizations and lower calix stones. Complete removal of foreign bodies and stones was performed. Foreign bodies were found to be embolization coils applied in the previous procedure.

Kidney Stones in Several Spinal Abnormalities: A Challenging Treatment.

Patients with severe skeletal deformities are a challenging group to treat. A female, white, 35-year-old presented with right kidney stones located in renal pelvis, lower calyx, and upper ureter. She was affected by severe spinal deformity with restrictive respiratory obstruction, caused by kyphoscoliosis. Percutaneous nephrolithotomy in supine position was performed, achieving complete removal of kidney stones. The treatment of renal stones in this patient was complex, so special attention to respiratory function was mandatory; this was a challenging but feasible situation.

Nephrolithiasis Greater Than 2 cm and Splenomegaly.

A 67-year-old male presented with left kidney stones in renal pelvis, 15 mm length. Preoperative CT showed massive splenomegaly. Retrograde intrarenal surgery approach was decided to avoid splenic injury, achieving the absence of residual stones.

Percutaneous management of staghorn calculi in horseshoe kidneys: a multi-institutional experience.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PNL) is a first-line management technique for staghorn stones and stones located in a horseshoe kidney (HK). We present our multi-institutional experience on the management of staghorn calculi within HKs. MATERIALS AND METHODS: The study included 15 patients with 17 staghorn calculi in HKs who were treated by PNL in six academic institutions. All PNL procedures were performed in a standard one-session technique with fluoroscopic guidance. The following information was assessed: Number of access dilations, renal access location, blood loss, blood transfusion, stone-free rate, length of hospitalization. Intraoperative and postoperative complications as well as secondary procedures (second-look PNL, ureteroscopy, and shockwave lithotripsy) were reviewed. RESULTS: Mean patient age was 50 years (range 24-72 y) years old. Subcostal (n = 16) or intercostal (n = 1) puncture was performed. The average anesthesia time was 126 minutes (93-200 min). The average blood loss was 450 mL, and transfusions were deemed necessary in 20% of the cases. Single skin incisions were made for the management of 11 renal units, and multiple incisions were made in 6. The average number of tract dilations per renal unit was 2.11 (range 1-4). The overall stone-free rate was 82%. The average length of hospital stay was 4.4 days (range 3-7). The average duration of nephrostomy tube drainage was 80 hours with a range of 72 to 96 hours. Major and minor complication rate was 20% and 46.6%, respectively. CONCLUSION: The performance of PNL is a safe and effective method to manage staghorn calculi in HKs.

Laparoscopic partial nephrectomy: current status.

OBJECTIVE: Increasingly nephro-sparing partial nephrectomy has became widely accepted as a preferred treatment option for the select patient when the adenocarcinoma involves a solitary kidney or poorly functioning contralateral kidney, and in patients with synchronous bilateral tumors. While open partial nephrectomy is currently the standard nephron sparing procedure for treatment of renal tumors, laparoscopic partial nephrectomy has emerged as a potential alternative recently. METHODS: This review seeks a critical assessment of the current status of laparoscopic partial nephrectomy, worldwide results and a brief description of energy based in-situ tumor ablation systems. We have duplicated laparoscopically, the open surgical techniques. While choice of laparoscopic approach depends upon the surgeon's personal preference, the precise location of the tumor on the kidney is the main factor determining our either retroperitoneal or transperitoneal approach. Hilar clamping reliably achieves a bloodless field, decreases renal turgor and allows surgical precision during tumor excision and control of larger vessels, which represents a real, practical and significant advantage. Precise suture repair currently remains the optimal and most reliable method for sealing a collecting system entry during the course of a laparoscopic partial nephrectomy. With increasing experience, laparoscopic partial nephrectomy can be safely applied to renal tumors that extend deeply, even upto the renal sinus. CONCLUSIONS: As more data emerges and the technical success rates of laparoscopic partial nephrectomy improve this minimally invasive technique will gain a wider role in the treatment of select renal cell carcinomas.

[Modified laparoscopic scissors: a new instrument for performing endopyelotomy]. / Tijera laparoscópica modificada: un nuevo instrumento para realizar endopielotomía.

OBJECTIVE: The safety and success of antegrade endopyelotomy in the treatment of ureteropelvic junction (UPJ) stenosis have been documented in numerous literature reports over the last decade. We show a new available alternative to the way incision is performed. METHODS: Endopyelotomy with modified laparoscopic scissors was performed in 18 patients; 12 presented with primary obstruction and 6 with secondary obstruction. 3 mm laparoscopic scissors with one end sharpened and adapted for this technique are introduced through a nephroscope. A small puncture through the renal pelvis wall is made in the posterolateral position using the scissors' end. After that, scissors are opened under permanent endoscopic control as far as to visualization of the peripyelic space, continuing then with the internal edge of the scissors down to the UPJ. Visual control allowed us to coagulate any vessel and to avoid the bigger calibre ones. At the end of the procedure an endopyelotomy stent was placed over the safety guide wire. RESULTS: Results were good in 17 patients (94%); symptomatic relief and adequate pass of contrast to proximal ureter were observed in the remaining case, although pyelocalicilar dilation was not improved. Three vessels adjacent to the UPJ (16.6%) were discovered through the performed pyelotomy incision. Operative times were lower than 2 hours. Blood losses were minimal and patient recovery uneventful allowing hospital discharges within 48 hours. CONCLUSIONS: To use 3 mm laparoscopic scissors allows to perform endopyelotomy without changing endoscopes, precisely cutting due to retroperitoneum visualisation, and offers the chance to coagulate small calibre vascular elements and to avoid those of bigger size.

Nefrectomía parcial laparóscopica: estado actual / Laparoscopic partial nephrectomy: current status

Objetivo: La cirugía conservadora renal se ha convertido en una opción terapéutica ampliamente aceptada cuando un adenocarcinoma involucra un riñón solitario o una pobre función renal contralateral y en pacientes con tumores sincrónicos bilaterales. Mientras la cirugía conservadora renal a cielo abierto es el procedimiento standard para el tratamiento de los tumores renales, la nefrectomía parcial laparoscópica ha emergido recientemente como una alternativa potencial. Métodos/resultados: Esta revisión busca una visión crítica del estado actual de la nefrectomía parcial laparoscópica con los resultados mundiales y una descripción breve de los sistemas de ablación in-situ con distintas fuentes de energía. Hemos duplicado por vía laparoscópica las técnicas a cielo abierto. Mientras el abordaje laparoscópico depende de la preferencia del cirujano, la localización precisa del tumor dentro del riñón es el factor principal determinante nuestro abordaje retroperitoneal o transperitoneal. El clampeo del hilio logra un campo exangüe, disminuye la turgencia renal y permite precisión quirúrgica durante la resección tumoral y el control de los vasos sanguíneos, representando una ventaja real, práctica y significativa. La sutura precisa representa el método más confiable de reparación de la apertura del sistema colector durante el curso de una nefrectomía parcial laparoscópica. Con la experiencia creciente la nefrectomía parcial laparoscópica puede ser aplicada con seguridad en tumores que penetran profundamente involucrando el seno renal. Conclusiones: Con la aparición de más casuística y con mejores índices de éxito de la nefrectomía parcial laparoscópica, esta técnica ganará un rol más amplio en el tratamiento conservador de carcinomas de células renales (AU)

Tijera laparoscópica modificada: un nuevo instrumento para realizar endopielotomía / Modified laparoscopic scissors: a new instrument for endopyelothomy

Objetivo: En la última década, numerosos reportes en la literatura han documentado la seguridad y el éxito del tratamiento de la estenosis pieloureteral con endopielotomía anterógrada. En este artículo mostramos una nueva alternativa disponible referente al modo de realizar la incisión. Método: La endopielotomía con tijera laparoscópica modificada fue realizada en 18 pacientes, 12 de los cuales presentaban obstrucción primaria y 6 presentaron obstrucción secundaria. Se introdujo en el nefroscopio una tijera laparoscópica de 3 mm con el extremo afilado y adaptado a esta técnica. Se realizó una pequeña punción con el extremo de la tijera atravesando la pared de la pelvis renal en posición posterolateral. Luego la tijera se abrió bajo control endoscópico permanente hasta visualizar el espacio peripiélico, continuando con un corte con el filo interno de la tijera en dirección a la unión pieloureteral. La visualización de cualquier vaso permitió coagularlo y evitar aquellos de mayor calibre. Finalizado el corte un tutor de endopielotomía fue colocado sobre la guía de seguridad. Resultados: Los resultados fueron buenos en 17 pacientes (94 por ciento) y en el caso restante (6 por ciento) se observó alivio sintomático con pasaje adecuado del contraste al uréter proximal pero sin hallar mejoría en la dilatación pielocalicial. 3 vasos adyacentes a la unión pieloureteral (16,6 por ciento) fueron descubiertos a través de la pielotomía realizada. El tiempo operatorio fue menor a 2 hs. La pérdida hemática fue mínima y la recuperación sin complicaciones permitiendo el egreso del paciente a las 48 hs. Conclusiones: El uso de la tijera laparoscópica de 3 mm permite realizar la endopielotomía sin intercambio de endoscopios, cortando precisamente al visualizar el retroperitoneo, con la posibilidad de coagular elementos vasculares de menor calibre y evitar aquellos de mayor tamaño (AU)