2022 Recommendations of the AFU Lithiasis Committee: Percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (Labate et al.) is the standard procedure for the treatment of large (≥2cm) kidney stones. The patient can be in prone or modified supine position. The puncture is performed under fluoroscopy and/or ultrasound guidance. The stone-free rate seems to be comparable between miniaturized and standard PCNL. Procedures performed with smaller diameter instruments tend to be associated with significant lower blood loss, but longer procedure times. The limitation of the number of percutaneous tracts results in better preservation of the kidney function and lowers the risk of complications. The use of tranexamic acid during PCNL may be interesting for reducing the bleeding risk, the transfusion rate, and possibly the intervention duration. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis [EAU 2022]) and their adaptability to the French context.

[Management of adult's renal and ureteral stones. Update of the Lithiasis Committee of the French Association of Urology (CLAFU). General considerations]. / Prise en charge urologique des calculs rénaux et urétéraux de l'adulte. Mise au point du Comité Lithiase de l'Association Française d'Urologie (CLAFU). Aspects généraux.

The Lithiasis Committee of the French Association of Urology (CLAFU) aimed to update the current knowledge about urolithiasis. This update will be divided into four parts: 1) general considerations; 2) the management of ureteral stones; 3) the management of kidney stones; 4) metabolic assessment and medical treatment of urolithiasis. Recent technicals advances helped the urologists to improve stones management: new extracorporeal shockwave lithotripsy (ESWL) devices, new flexible ureterorenoscopes, development of laser fragmentation. ESWL, semi-rigid and flexible ureteroscopy and the percutaneous nephrolithotomy (PCNL) remain currently the main therapeutic options. The first part of this update deals with the description and classification of stones, preoperative assessment, post-operative management and clinical follow-up. Main criteria of therapeutic choices are stone location, stone composition and stone size. Stone composition is assessed with infrared spectrophotometry analysis and its hardness is correlated with U.H. density on CT scan assessment. Preoperative assessment consists in urinary cytobacteriological examine, urinary PH, blood creatininemia, hemostasis. Low-dose CT scan is recommended before urological treatment. The result of the treatment must be done 1 or 3 months later with plain abdominal film and ultrasonography. Medical management of urolithiasis will be based on stone composition, metabolic and nutritional evaluation. Treatment success is definited by absence of residual fragments. Annual follow-up is recommended and based either on plain abdominal film and ultrasonography or low-dose CT scan.

[Place of the flexible ureterorenoscopy first choice for the treatment of kidney stones. Survey results practice committee of the AFU lithiasis completed in 2011]. / Place de l'urétérorénoscopie souple en première intention pour le traitement des calculs du rein. Résultats de l'enquête de pratique du comité lithiase de l'AFU réalisée en 2011.

UNLABELLED: The flexible ureterorenoscopy coupled with photovaporisation LASER (USSR-L) for the treatment of kidney kidney is a modern tool whose place is under evaluation. METHODS: Its place has been assessed in France in 2010 by the Committee of urolithiasis of the French Association of Urology (CLAFU). A practice survey among 27 experts concerned the following decision criteria: comorbid patient's supposed nature of the calculation, anatomy of the urinary tract of the patient. This investigation has been proposed to calculate the size not exceeding 20mm, for a calculation of size greater than 20mm and for multiple calculations kidney. RESULTS: Fourteen experts responded. The criteria for the USSR-The first line were: morbid obesity (BMI>30), anticoagulation or anti platelet aggregation, calculations Hard (UH>1000, cystine stones), calculations within diverticular caliceal calculations below, the failure of a first treatment or the wish of the patient. CONCLUSION: The URS-SL was a first-line treatment validated regardless of size and number of kidney stones, when ESWL and PCNL were contraindicated or when their predictable results were poor (hard stones/morbid obesity/lower pole stones) or when stone access is difficult (intradiverticular). It was also the treatment of choice after the failure of a first treatment (ESWL/PCNL).

[Pathologic diagnosis and management of flat lesions of urothelium detected with aminolevulinic acid (Hexvix®)]. / Diagnostic anatomopathologique et prise en charge clinique des lésions planes urothéliales détectées à l'aide de l'acide aminolevulinique (Hexvix®).

INTRODUCTION: The aim of the study was to review the most important flat lesions, to demonstrate the difficulty of classifying several lesions, to introduce to urologists the new problems linked to FD and to suggest new models for accurate analysis. MATERIALS AND METHODS: Data about urothelial carcinomas and flat lesions and fluorescence were searched on MEDLINE by using the following keywords: cystoscopy; fluorescence; flat lesion; carcinoma in situ; metaplasia; bladder carcinoma. RESULTS: No evidence 1 level data was available. Flat lesions are a new challenge in pathology and urology. As urologists have a better sight of bladder lesions with fluorescence diagnosis (Hexvix(®)), pathologists will be asked in the future to evaluate more frequently flat lesions, which are sometimes difficult to classify and for which interobserver agreement is not always evident. CONCLUSION: It is essential to determine accurate histologic criteria, able to recognize flat lesions of the bladder and permitting adequate patients' treatment. Further studies with larger cohort of patients are needed to validate preliminary results obtained with fluorescence and to improve our knowledge of the natural history of these tumours.

[Simultaneous bilateral percutaneous nephrolithotomy: Series of 60 cases]. / Néphrolithotomie percutanée bilatérale en un temps: série de 60 cas.

OBJECTIVE: Retrospective evaluation of the efficacy and morbidity of simultaneous bilateral percutaneous nephrolithotomy (SB-PCNL). METHODS: From January 1993 to July 2009, 60 patients have undergone SB-PCNL over a series of 1709 PCNL. Thirty men and 30 women, mean age 45 years old (13-78), were treated for bilateral renal stones (120 kidneys) of 1177 mm(2) (268-4972 mm(2)); 25 were complete staghorn stones. RESULTS: Operating time for the first side of PCNL was 80 min (30-270) and 45 min (10-90) for the opposite side. Overall OR occupation was 188 min (90-360). Forty-five patients were stone free after one session; 15 patients (25%) have a complementary treatment to be stone free: five PCNL (one bilateral); eight ESWL (four with JJ stent) and two flexible ureteroscopy. No blood transfusion was required. Renal function was unchanged at 1 month. Clavien grade for complications were as follows: two grade IIIb, one grade IVa and one grade IVb. Hospitalization stay was 4±4.9 days (2-35) taking account of two major sepsis (one pulmonary and one septicemia). CONCLUSION: SB-PCNL was well tolerated with comparable morbidity and efficacy to PCNL performed on each side in two separate sessions. Nevertheless, SB-PCNL has to be performed for selected patients in expert centers.

[Results of nephron-sparing surgery for renal cell carcinoma of more than 4 cm in diameter]. / Résultats de la néphrectomie partielle pour les carcinomes à cellules rénales de plus de 4cm.

To date, radical nephrectomy (RN) remains the gold standard treatment for renal cell carcinoma (RCC) larger than 4 cm. However, from the early 1990's, improvements in surgical techniques have lead to the development of nephron-sparing surgery (NSS) for small renal tumours of less than 4 cm in diameter. This surgical procedure avoids nephronic waste with an acceptable morbidity and similar oncological outcomes compared to radical surgery. Recent large published series did not show any difference between NSS and RN in terms of oncological safety. Specific and disease-free five-year survival rates (82% to 97.3% and 81% to 97.3%, respectively) have confirmed the safety of NSS. Regarding laparoscopic NSS, the technique is still under evaluation and only mid-term outcomes are available so far. However, these studies are still limited and longer follow-up is needed before any definitive statement can be made. Current guidelines recommend NSS only in case of RCC of less than 4 cm in diameter in elective indications. In daily practice however, surgical teams are pushing back the limit above the threshold of 4 cm. More and more surgeons are either considering anatomical location or technical expected difficulties rather than just the tumour size. NSS leads to higher risk of bleeding, especially in case of tumours larger than 4 cm. Therefore, it is absolutely necessary to investigate thoroughly the vascularization of the tumour to avoid such complications with exhaustive and accurate preoperative imaging.

[Characteristics of encrustation of ureteric stents in patients with urinary stones]. / Caractéristiques des incrustations des endoprothèses urétérales chez les patients lithiasiques.

INTRODUCTION: The goal of this prospective study was to characterize ureteral stents encrustation in stone formers. MATERIAL AND METHODS: We report the results of a study based on 658 double-J stents (412 men and 246 women) collected from patients with in situ urinary calculi. The mean age was 48.2+/-16.0 years without differences between genders. Ureteral stent encrustation was analysed by infrared spectroscopy. Results are expressed according to the main component. RESULTS: The mean indwelling time was 73.5+/-73.2 days. The main component in stent encrustations was calcium oxalate (43.8%), essentially the monohydrate form (27.1%), followed by proteins (27.4%), calcium phosphates (16.4% with 8.4% brushite), and uric acid (5.2%). Struvite, detected on 49 stents, was the main component in 2.4% of cases. Significant differences according to gender and age were found: calcium oxalate monohydrate, which represented 24.5% in 20 to 29 years old men class increased to 37.0% in 50 to 59 years class and then decreased in older patients. Calcium oxalate dihydrate increased with age up to 70 years in women while it felt dramatically in man beyond 50 years old. Brushite was more abundant in young men (20.4% in patients aged 20-29 years) and was decreasing beyond this age while it remained in stable proportion for all age classes in women. Increasing prevalence of uric acid encrustations with age was observed, especially in men beyond the age of 70 years. Mineral encrustations increased with the indwelling time, the part of mineral being preponderant after 15 days: 7,3% of the stents had become massively encrusted within 113 days mean period. The comparison between biomaterials showed that silicone stents were significantly less encrusted than polyurethane stents. CONCLUSION: Stent encrustation constitutes a serious complication of ureteral stent use in stone formers. Lithogenic factors should be considered for the prevention of stent encrustation in these patients.

[Colonic tubular adenoma following ureterosigmoidostomy: CT features]. / Adénome colique tubuleux après urétérosigmoïdostomie: aspect tomodensitométrique. à propos d'un cas.

We report a case of benign colonic tubular adenoma arising in a 36-year-old female at the site of ureterosigmoidostomy performed 25 years before. The tumor was revealed by recurrent episodes of pyelonephritis; hydronephrosis was present. On colonic enema, the tumor appeared lobulated, 4 cm in diameter. CT scan showed a multiloculated mass, which enhanced after injection. Pathology revealed a tubular adenoma of the colon with cystic dilatation of glandular structures. The role of imaging studies in the follow-up of patients after ureterosigmoidostomy is discussed.

[Spontaneous intraperitoneal rupture of the ureter]. / Rupture intrapéritonéale spontanée de l'uretère.

An unusual case of spontaneous intraperitoneal rupture of the ureter was observed in adult with acute renal pain. Diagnosis was best established with CT rather than intravenous urography. CT demonstrated ureteral leakage with the contrast medium extravasating into the peritoneal cavity. The patient was initially managed successfully by endourology. Secondary stenosis of the ureter required surgery for partial resection of the distal ureter.

[Enkephalinergic receptors at the level of the lower urinary tract]. / Les récepteurs enképhalinergiques au niveau du bas appareil urinaire.

After describing the autonomic nervous system of the lower urinary tract and its neurotransmitters, the authors discuss the recent discovery of new endomorphine group mediators--the enkephalins. There exist enkephalin immunoreactive nerve fibers in the smooth muscles of the bladder and the prostate. This neuromediator is synthetized in the spinal cord in the body of the preganglionic neuron and is carried by the axon flow towards the intramural parasympathetic ganglions of the bladder. The physiological effects of enkephalins are similar to those of morphinics and are antagonized by naloxone. Enkephalins inhibit spontaneous or provoked contractions of the bladder by inhibiting action on the parasympathetic neurons. This property of relaxing the muscles of the bladder, in both volume and pressure, may open up new vistas for uropharmacological research.

[Extracorporeal electromagnetic shock-wave lithotripsy. Initial results in the treatment of ureteral calculi in situ. A series of 50 consecutive cases]. / Lithotripsie extra-corporelle par ondes de choc électromagnétiques. Premiers résultats dans le traitement de la lithiase urétérale in situ. Série de cinquante cas consécutifs.

Electromagnetic shock waves are sufficiently powerful to break ureteral stones in situ under X-ray control. Fifty consecutive patients were treated for ureteral stones (20 lombar, 4 iliac, 26 pelvic); the average length was 7.5 mm; 48 times in one session, twice in two sessions. At 6 months, 98% of these patients were stone-free (with IVP control) and one patient was lost to follow-up.

[Vascularization of a pedicled flap intended for the urethra]. / Etude de la vascularisation des lambeaux pédiculés à destinée urétrale.

One stage urethroplasties using a cutaneous island pedicle flap have been described by Quartey, Orandi, Marberger, Gattegno and Blandy. Anatomical study after colored injection and dissection shows, for each of them, a good blood supply from large anastomoses between the internal and external pudendal arteries. The pedicle is very well individualized on Quartey's flap.

[Cystine lithiasis and extracorporeal lithotripsy]. / Lithiase cystinique et lithotripsie extra-corporelle.

ESWL using the HM3 Dornier lithotriptor is a new therapeutic method for cystine stone disease, particularly in patients who have undergone several surgical procedures with or without adjuvant dissolving drugs. We report 3 cases, demonstrating satisfactory fragmentation results. However the rate of stone-free patients was much lower. This situation might be improved by the adjuvant use of dissolving drugs. The preliminary results (Feb 1988) of the European multicenter study (61 cases in 10 centers), confirm our own experience with a 90% fragmentation rate and only 30% stone-free rate for kidney stones and 77% for ureteral stones.

[Fibrous polyps of the urinary tract]. / Polypes fibreux de la voie excrétrice.

The authors report five cases of fibrous polyps of the urinary tract, which is a rare disease, as Mazeman only reported 12 cases in his review in 1972. These cases confirm the polymorphic nature of the clinical presentation and the site of these tumours of mesodermal origin, essentially composed of richly vascular connective tissue covered with surface epithelium. Treatment is surgical and conservative. The authors performed two junctional resections, one ureterotomy, one ureteroscopic resection and one nephro-ureterectomy for a partially destroyed kidney.

[How to plan the treatment of prostatic adenoma today?]. / Comment concevoir aujourd'hui le traitement de l'adénome prostatique?

Surgical treatment, mainly transurethral resection of the prostate, still remains the reference treatment for benign prostatic hyperplasia (BPH). Two studies conducted in the Urology Department of the Pitié-Salpêtrière Hospital have tried to define certain characteristics of this surgery. The first study tried to evaluate the long-term outcome of patients operated for benign prostatic hyperplasia. Analysis of 881 replies to a questionnaire sent to 3,147 patients operated for BPH (between 1976 and 1989) assessed functional status (by Madsen's symptom score), quality of life (by Fowler's method), and sex life (by two specific questions), with a follow-up ranging from 5 to 14 years. At this follow-up, 90% of patients declared to be satisfied with their voiding status, 95% considered their quality of life to be excellent and about 50% had maintained a sex life. The second study was designed to evaluate the morbidity of this treatment in elderly patients. A group of 33 operated patients over the age of 80 was compared to a control group composed of 66 patients between the ages of 60 and 70 years, treated in a similar way, in the same centre and in the same year. Morbidity was higher in the first group, but age itself did not appear to constitute a poor prognostic factor for surgery; it only intervenes by allowing certain complications of benign prostatic hyperplasia (acute retention) to create emergency situations complicating the perioperative period. Following demonstration of the short-term and long-term efficacy of this conventional surgery, many new technologies were subsequently developed in order to reduce perioperative discomfort, anaesthetic requirements, duration of catheterization and hospital stay. Some of them constitute a new approach to endoscopic surgery, such as prostatic tissue vaporization techniques (electrovaporization, laser contact vaporization), which have a comparable efficacy to that of TURP, while reducing bleeding, catheterization time and hospital stay. However, the duration of postoperative irritative symptoms is much longer. Other techniques use a thermal effect to obtain coagulation necrosis of prostatic tissue, using various energy sources: microwaves (thermotherapy), laser (interstitial laser), radiofrequency waves (TUNA). These techniques are perfectly adapted to outpatient surgery with local or regional anaesthesia. They do not interfere with continence, sexual function, but may be followed by high dysuria or retention rates, with a variable cathererization time, sometimes several weeks. Finally, urethroprostatic stents are easy to insert, provide a solution in critical situations and have replaced old indwelling catheters. The current choice of treatment therefore comprises several approaches: more effective, but still purely symptomatic medical treatment, safe conventional surgery providing excellent long-term results, but generating a certain perioperative discomfort and a certain morbidity, or, on the contrary "minimally invasive" techniques, greatly simplifying the therapeutic procedure, but whose morbidity has not yet been determined and whose results are still uncertain.

[Malformation of the renal venous system and caudal vena cava presenting as recurrent hematuria]. / Malformation du système veineux rénal et cave caudal révélée par des hématuries récidivantes.

The authors report a case of haematuria secondary to ureteric varices due to a complex venous malformation. After excluding a neoplastic and infectious cause, this rare cause of haematuria must be considered in patients presenting with unilateral upper tract haematuria. In this case, the diagnosis was made during adulthood. It was suspected on intravenous urography and confirmed by computed tomography.

[Portal hypertension: a rare cause of hematuria]. / L'hypertension portale: une cause rare d'hématurie.

A patient with undiagnosed cirrhosis presented with massive haematuria 16 years after augmentation colonoplasty. Portal hypertension (PHT) was responsible for a portocaval collateral circulation with vesical varices detected by low pressure endoscopy performed between episodes of haematuria. A very similar case was published in 1991. Surgical haemostatis with partial or total resection of the colonoplasty was only temporarily effective in our patient, who subsequently underwent liver transplantation due to repeated episodes of hepatic encephalopathy. No recurrence of haematuria was observed six years after the diversion. This rare cause of haematuria must be considered in view of the widespread use of intestinal conduits in urology: a dozen cases have been reported after transileal cutaneous ureterostomy, occurring an average of 3 years after the operation. Direct treatment of the varices, either by surgical devascularisation or resection or be endoscopic laser sclerosis or coagulation, is only temporarily effective. Treatment of the PHT appears to be the most effective measure in the long term: beta-blockers administered in the absence of episodes of haematuria or portal by-pass surgery in the case of failure.

[Posterior vertical lumbar incision in the treatment of pyelo-ureteral junction anomaly: report of 71 cases]. / La lombotomie verticale postérieure dans le traitement de l'anomalie de la jonction pyélo-urétérale: à propos de 71 cas.

Posterior vertical lumbar incision, described for the first time in 1869 by Simon, provides a simple access to the kidney and offers excellent exposure of the ureteropelvic junction. The technical modifications proposed by Gil Vernet facilitate access to the kidney and reduce the morbidity. The operative technique is described in detail and the authors report their retrospective experience of 71 cases of correction of ureteropelvic junction anomalies (stage 2, 3 and 4). The morbidity was low (19%). Patients returned to work by the 3rd week. 88% of good results were observed at 3 months (84% in initial stage and 4 lesions). This approach should be preferred to the lateral incision or the percutaneous approach due to the simplicity of the technique and the low complication rate.

[High intensity focused ultrasound (HIFU) in urology]. / Les ultrasons focalisés de haute intensité (UFHI) en urologie.

INTRODUCTION: Focused ultrasound is now well known to urologists in the context of its validated application in extracorporeal lithotripsy. High Intensity Focused Ultrasound (HIFU) represents a potential therapeutic modality for tissue destruction due to its very high energy and its capacity to precisely reach a target with a very short emission time. The authors review the current state of art of HIFU in urology at a time when its indication in prostate cancer is being defined. MATERIAL AND METHOD: After a brief description of the main physical principles of ultrasound and the main data determining focussing of high energy ultrasound, the main machines available (research and clinical) are described. The published clinical literature concerning the tissue destructive action in urology is reviewed. RESULTS: HIFU has been used in urology to treat renal, vesical, prostatic (BPH and cancer), and external genital organ lesions. Purely extracorporeal machines are gradually being replaced by intracorporeal procedures, especially transrectal techniques for prostatic lesions. The quality of ultrasound detection of the target still limits the use of this minimally invasive modality. The intervening tissues are spared with a good therapeutic efficacy on the target tissues, provided optimal firing parameters are used. CONCLUSION: HIFU has a demonstrated potential in the treatment of prostate cancer and studies conducted by several teams have defined the technique and its efficacy. Other indications have been studied, but must be validated by further clinical trials. The future will probably see the design of machines adapted to a specific target tissue rather than a single multidisciplinary extracorporeal machine.

[Assessment of hemorrhage risk of transvesical prostatectomy with bladder neck cerclage]. / Evaluation du risque hémorragique des adénomectomies transvésicales avec cerclage du col.

OBJECTIVE: Evaluation of blood loss and predictive factors of haemorrhagic complications of transvesical prostatectomy. MATERIAL AND METHODS: From January 1994 to December 1998, 202 patients with a mean age of 70.5 +/- 7.4 years (range: 46.6-89.3 years) were operated for benign prostatic hyperplasia with a mean prostate weight of 86 +/- 33 g. Transvesical prostatectomy was performed with bladder neck cerclage and suction drainage of the prostatectomy site for 48 hours. 107 patients donated blood preoperatively (mean: 2.8 +/- 0.7 units) to allow possible autotransfusion. Blood losses were evaluated by determining haematocrit during hospitalisation, the quantity of blood collected intraoperatively and the presence of postoperative bleeding possibly requiring surgical revision. RESULTS: The calculated overall blood loss was 435 +/- 306 ml of RBC, i.e. 1783 ml for an haematocrit of 30%. A high ASA score was significantly related with higher blood loss and preoperative anticoagulant treatment. No predictive factor for intraoperative bleeding (mean: 519 +/- 327 ml) was identified. Absence of the median lobe and a high ASA score were also predictive factors of postoperative bleeding. Age, operating time, prostate weight, recent urinary tract infection, preoperative drainage, preoperative haematocrit, and preoperative blood donation (autotransfusion) did not significantly influence the volume of blood loss. CONCLUSION: Apart from the ASA score, no predictive factor for the severity of bleeding associated with transvesical prostatectomy was defined in order to identify a group of patients at higher risk of severe bleeding.