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.
Purpose We evaluated which variables impact fragmentation and clearance of lower pole calculi after shock wave lithotripsy. Materials and Methods We prospectively evaluated patients undergoing shock ...wave lithotripsy for a solitary 5 to 20 mm lower pole kidney stone between June 2012 and August 2014. Patient body mass index and abdominal waist circumference were recorded. One radiologist blinded to shock wave lithotripsy outcomes measured stone size, area and density, stone-to-skin distance, infundibular length, width and height, and infundibulopelvic angle based on baseline noncontrast computerized tomography. Fragmentation, success (defined as residual fragments less than 4 mm in asymptomatic patients) and the stone-free rate were evaluated by noncontrast computerized tomography 12 weeks postoperatively. Univariate and multivariate analysis was performed. Results A total of 100 patients were enrolled in the study. Mean stone size was 9.1 mm. Overall fragmentation, success and stone-free rates were 76%, 54% and 37%, respectively. On logistic regression body mass index (OR 1.27, 95% CI 1.11–1.49, p = 0.004) and stone density (OR 1.0026, 95% CI 1.0008–1.0046, p = 0.005) significantly impacted fragmentation. Stone size (OR 1.24, 95% CI 1.07–1.48, p = 0.039) and stone density (OR 1.0021, 95% CI 1.0007–1.0037, p = 0.012) impacted the success rate while stone size (OR 1.24, 95% CI 1.04–1.50, p = 0.029), stone density (OR 1.0015, 95% CI 1.0001–1.0032, p = 0.046) and infundibular length (OR 1.1035, 95% CI 1.015–1.217, p = 0.015) impacted the stone-free rate. The best outcomes were found in patients with a body mass index of 30 kg/m2 or less, stones 10 mm or less and 900 HU or less, and an infundibular length of 25 mm or less. The coexistence of significant unfavorable variables led to a stone-free rate of less than 20%. Conclusions Obese patients with higher than 10 mm density stones (greater than 900 HU) in the lower pole of the kidney with an infundibular length of greater than 25 mm should be discouraged from undergoing shock wave lithotripsy.
Abstract Context Recent advances in technology have led to the implementation of mini– and micro–percutaneous nephrolithotomy (PCNL) as well as retrograde intrarenal surgery (RIRS) in the management ...of kidney stones. Objective To provide a systematic review and meta-analysis of studies comparing RIRS with PCNL techniques for the treatment of kidney stones. Evidence acquisition A systematic literature review was performed in March 2014 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. A subgroup analysis was performed comparing standard PCNL and minimally invasive percutaneous procedures (MIPPs) including mini-PCNL and micro-PCNL with RIRS, separately. Evidence synthesis Two randomised and eight nonrandomised studies were analysed. PCNL techniques provided a significantly higher stone-free rate (weighted mean difference WMD: 2.19; 95% confidence interval CI, 1.53–3.13; p < 0.00001) but also higher complication rates (odds ratio OR: 1.61; 95% CI, 1.11–2.35; p < 0.01) and a larger postoperative decrease in haemoglobin levels (WMD: 0.87; 95% CI, 0.51–1.22; p < 0.00001). In contrast, RIRS led to a shorter hospital stay (WMD: 1.28; 95% CI, 0.79–1.77; p < 0.0001). At subgroup analysis, RIRS provided a significantly higher stone-free rate than MIPPs (WMD: 1.70; 95% CI, 1.07–2.70; p = 0.03) but less than standard PCNL (OR: 4.32; 95% CI, 1.99–9.37; p = 0.0002). Hospital stay was shorter for RIRS compared with both MIPPs (WMD: 1.11; 95% CI, 0.39–1.83; p = 0.003) and standard PCNL (WMD: 1.84 d; 95% CI, 0.64–3.04; p = 0.003). Conclusions PCNL is associated with higher stone-free rates at the expense of higher complication rates, blood loss, and admission times. Standard PCNL offers stone-free rates superior to those of RIRS, whereas RIRS provides higher stone free rates than MIPPs. Given the added morbidity and lower efficacy of MIPPs, RIRS should be considered standard therapy for stones <2 cm until appropriate randomised studies are performed. When flexible instruments are not available, standard PCNL should be considered due to the lower efficacy of MIPPs. Patient summary We searched the literature for studies comparing new minimally invasive techniques for the treatment of kidney stones. The analysis of 10 available studies shows that treatment can be tailored to the patient by balancing the advantages and disadvantages of each technique.
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.
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.
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.
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.
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).
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.
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.
Success rates in endourological procedures, notably percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS), have demonstrated suboptimal outcomes, leading to more reinterventions and radiation ...exposure. Recently, the use of intraoperative computed tomography (ICT) scans has been hypothesized as a promising solution for improving outcomes in endourology procedures. With this considered, we conducted a comprehensive systematic review and meta-analysis encompassing all available studies that evaluate the impact of the use of intraoperative CT scans on surgical outcomes compared to conventional fluoroscopic-guided procedures.
This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were systematically searched up to December of 2023. This study aimed to directly compare the use of an ICT scan with the standard non-ICT-guided procedure. The primary endpoint of interest was success rate, and the secondary endpoints were complications and reintervention rates, while radiation exposure was also evaluated. Data extraction and quality assessment were performed following Cochrane recommendations. Data was presented as an Odds ratio with 95%CI across trials and a random-effects model was selected for pooling of data.
A comprehensive search yielded 533 studies, resulting in the selection of 3 cohorts including 327 patients (103 ICT vs 224 in non-ICT). Primary outcome was significantly higher in the experimental group versus the control group (84.5% vs 41.4% respectively, 307 patients; 95% CI 3.61, 12.72; p<0.00001; I2=0). Reintervention rates also decreased from 32.6% in the control to 12.6% in the ICT group (OR 0.34; 95%CI 0.12,0.94; p =0.04; I2= 48%), whereas complication rates did not exhibit significant differences. Radiation exposure was also significantly reduced in two of the included studies.
This meta-analysis highlights a favorable outcome with intraoperative CT scan use in PCNL procedures, showing a considerable increase in SFR when compared to standard fluoroscopy and nephroscopy. Despite limited studies, our synthesis underscores the potential of ICT scans to significantly reduce residual stones and their consequences for endourology patients, as reinterventions and follow-up ionizing radiation studies.
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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