Purpose The purpose of this guideline is to provide a clinical framework for the diagnosis, prevention and follow-up of adult patients with kidney stones based on the best available published ...literature. Materials and Methods The primary source of evidence for this guideline was the systematic review conducted by the Agency for Healthcare Research and Quality on recurrent nephrolithiasis in adults. To augment and broaden the body of evidence in the AHRQ report, the AUA conducted supplementary searches for articles published from 2007 through 2012 that were systematically reviewed using a methodology developed a priori . In total, these sources yielded 46 studies that were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as Clinical Principles and Expert Opinions. Results Guideline statements were created to inform clinicians regarding the use of a screening evaluation for first-time and recurrent stone formers, the appropriate initiation of a metabolic evaluation in select patients and recommendations for the initiation and follow-up of medication and/or dietary measures in specific patients. Conclusions A variety of medications and dietary measures have been evaluated with greater or less rigor for their efficacy in reducing recurrence rates in stone formers. The guideline statements offered in this document provide a simple, evidence-based approach to identify high-risk or interested stone-forming patients for whom medical and dietary therapy based on metabolic testing and close follow-up is likely to be effective in reducing stone recurrence.
Purpose The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria. Materials and Methods A systematic literature ...review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements. Results Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up. Conclusions AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic_microhematuria_guideline.pdf to view this guideline in its entirety.
Purpose
Percutaneous nephrolithotomy (PCNL) is performed commonly in patients with large kidney stones, but the management of their postoperative pain presents a major challenge. While it is not ...routinely performed in PCNL patients, paravertebral block (PVB) has been described as an effective strategy for pain control after various non-urologic surgeries. This trial aims to assess the effect of paravertebral blockade on intraoperative and postoperative opioid use as well as postoperative pain control in patients undergoing PCNL.
Methods
This was a prospective, randomized, double-blind, placebo-controlled study. Patients who consented to participate were randomly assigned to undergo either PVB or a placebo intervention preoperatively. The patient, surgeon, and anesthesia team were all blinded to the randomization. The outcome parameters were intraoperative opioid requirement, postoperative visual analog scale (VAS) pain scores, postoperative opioid use, and postoperative antiemetic use.
Results
23 patients were enrolled in each arm of the study, and the two groups had no significant differences in baseline demographic or clinical characteristics. Patients in the PVB group had significantly lower intraoperative opioid use, postoperative opioid use, frequency of opioid use, and antiemetic. Patients in the PVB group also had lower postoperative VAS pain scores. There were no patients who suffered from complications attributable to PVB.
Conclusion
The results of this randomized, double-blind, placebo-controlled trial suggest that PVB should be considered an effective strategy to reduce opioid requirement and improve pain control for patients undergoing PCNL.
Purpose The increased use of abdominal imaging has led to more frequent detection of incidental renal cysts. Since the inception of the Bosniak classification system, management of Bosniak I, III and ...IV cysts has been clearly defined, while evaluation and management of Bosniak II and IIF cysts have remained a clinical dilemma. Discussions of new imaging modalities are becoming increasingly prevalent in the radiological literature. In this context we performed a comprehensive review of the recent literature on complex renal cysts focusing on new imaging modalities, surveillance strategies and biopsy. Materials and Methods We performed a comprehensive literature review of articles published from January 1, 1998 through December 31, 2013 via MEDLINE® , EMBASE and the Cochrane Collection using a predetermined search strategy. All studies included were performed in humans older than 18 years, were written in English and had an abstract available for review. We grouped studies into 1 of 5 categories, ie computerized tomography, magnetic resonance imaging, ultrasound, biopsy and surveillance. Results While computerized tomography and magnetic resonance imaging with and without contrast enhancement remain the gold standard to evaluate cystic lesions of the kidney, diffusion-weighted magnetic resonance imaging and contrast enhanced ultrasound have surfaced as new tools for assessment of complex cysts. Comparative effectiveness studies on these new imaging modalities are limited. Image guided biopsy has increasingly been shown to be useful for evaluation of intermediate (Bosniak II and IIF) complex cysts. We found few studies providing guidance on the duration and/or intensity of surveillance required for intermediate complex renal cysts. Conclusions Although new and enhanced techniques are in development and may be useful in the future management of complex renal cysts, there is a paucity of data regarding the value of these new techniques. Future research should focus on surveillance of intermediate complex renal cysts, particularly on the ideal frequency and type of imaging required.
Purpose Laparoscopic living donor nephrectomy is now the preferred technique for living donor renal transplantation. To our knowledge we provide the first published multi-institutional consensus ...describing practice patterns, technical considerations and interesting controversies involved in laparoscopic living donor nephrectomy. Materials and Methods We designed a survey with 33 multiple choice questions looking at demographics, patient selection, technical considerations, postoperative care and followup involved in laparoscopic living donor nephrectomy. Surveys were sent to the 58 fellowship training programs in the United States accredited by the American Society of Transplant Surgeons. Results The 32 responding programs performed approximately 40% of laparoscopic living donor nephrectomies in the United States in 2005. We found that almost all centers used a donor committee to screen candidates, enforce a body mass index cutoff, and use right kidneys when necessary and left kidneys in women of childbearing age. Regarding laparoscopic access, pure laparoscopy was favored 2 to 1 over the hand assisted technique and most of those who use nonbladed trocars do not close the fascia. Most surgeons divide the adrenal vein in left cases, use a vascular stapler on the renal artery and vein, and keep the ureter with the gonadal vein in the specimen. At most centers heparin is given before controlling the vessels. Extraction in pure laparoscopic cases is usually performed using a preplaced entrapment bag through a modified Pfannenstiel incision. Conclusions Our survey describes how most renal transplant centers with accredited fellowship programs in the United States approach laparoscopic living donor nephrectomy. Specifically trends are revealed regarding patient selection, laparoscopic access and surgical technique.
Objectives To evaluate the durability of 4 next-generation flexible ureteroscopes in a randomized, multi-institutional, prospective study. Methods Patients at 3 institutions were randomized to 1 of 4 ...flexible ureteroscopes: the Wolf Viper, Olympus URF-P5, Gyrus-ACMI DUR-8 Elite (DUR-8E), and Stryker FlexVision U-500. Each center used 1 scope from each manufacturer until it needed major repair (primary endpoint). Intraoperative data included total time of use, number of scope insertions through an access sheath, working time in the lower pole, number of insertions and total time for accessory instrumentation in the working channel, number of laser insertions through the working channel, and total laser energy used. Results A total of 175 patients were randomized. The DUR-8E experienced early catastrophic failure (≤ 10 cases) at all 3 sites; however, this also occurred at 1 site each for the Stryker and Wolf scopes. The DUR-8E required major repair after the fewest average number of cases (5.3), the lowest average total time of usage (108 minutes), the fewest insertions through an access sheath (20.3), the shortest duration of laser firing (31.3 minutes), and the shortest instrument in the working channel time (224.7 minutes). As such, due to variation in durability within manufacturers, no differences could be demonstrated. Visibility ratings for the Wolf iper were significantly better than the DUR-8E ( P = .034) and the Flexvision ( P = .038). Conclusions The Wolf Viper, Olympus URF-P5, and Stryker Flexvision U-500 flexible ureteroscopes seem comparable with regard to durability. However, larger prospective registry-based studies are needed to document significant differences between them.
More than 40% of patients undergoing percutaneous nephrolithotomy (PCNL) are left with residual stone fragments and often require secondary procedures. Portable CT (PCT) technology allows surgeons to ...obtain intraoperative cross-sectional imaging, identify and extract residual stones immediately, and thereby reduce the need for subsequent procedures. This prospective trial evaluates how incorporation of PCT during PCNL affects perioperative outcomes.
We prospectively enrolled eligible patients undergoing initial PCNL for this trial (
= 60), which entailed a single intraoperative CT abdomen and ipsilateral antegrade ureteroscopy when the surgeon felt stone treatment was visually complete. If residual fragments were identified, the surgeon continued nephroscopy to find and remove them; if not, the procedure was concluded. These patients were compared with a retrospective cohort (
= 174) who underwent initial PCNL with postoperative imaging performed the following day.
The two cohorts had similar demographic properties and stone characteristics, and location of percutaneous access. In the prospective arm, 50% of intraoperative PCT scans identified residual fragments, prompting continuation of surgery to remove them. This cohort had significantly higher stone-free rate (82%
36%,
< 0.01), lower rate of planned reintervention (7%
32%,
< 0.01), lower rate of urgent presentation with ureteral obstruction (0%
7%,
= 0.04), lower total CT-based effective radiation dose (8.4 mSv
14.6 mSv,
< 0.01), and shorter length of stay (2.3 days
3.5 days,
< 0.01) when compared with the retrospective cohort that did not use intraoperative PCT.
Obtaining an intraoperative PCT scan during PCNL can substantially improve perioperative outcomes. Further evaluation of this modality through a randomized controlled trial is warranted. Clinical Trial Registration Number: NCT04556396.
Introduction
Proton-pump inhibitors (PPIs) may increase the risk of kidney stone formation, but the mechanism has not been elucidated. There is a paucity of literature evaluating the effects of PPIs ...on urinary metabolites and urine pH.
Methods
We performed a retrospective review of nephrolithiasis patients treated at our institution and compared patients who were taking PPIs to those who were not at the time of their 24-h urine collections. Hierarchical multivariate linear regression was used to evaluate the independent relationship between PPI use and urinary mineral composition.
Results
We identified 301 consecutive patients, 88 (29%) of whom were taking PPIs at the time of their 24-h urine collections. Patients taking PPIs were older and more likely to have medical comorbidities associated with metabolic syndrome such as hypertension, diabetes, and dyslipidemia (
p
< 0.01). Controlling for these factors, patients taking PPIs were found to have 12% lower 24-h urine citrate excretion (
β
= − 0.12, Δ
F
= 4.24,
p
= 0.04). There were no other differences in urinary mineral composition between the groups.
Conclusion
Our findings suggest that patients who take PPIs regularly may be at risk for decreased urinary citrate excretion. The consequent decrease in urinary citrate may become clinically significant for patients with other predisposing factors for hypocitraturia.
The management of the forgotten, encrusted, calcified (FECal) Double-J ureteral stents can represent one of the most difficult and challenging surgical conditions for the practicing urologist. We ...present a novel and simple grading system for the FECal stent and, taking into account our own experience and literature review, propose an algorithm in the management of the encrusted stent based on this new system.
A retrospective analysis of our stone database was performed from March 2000 to April 2007 revealing a total of nine patients presented with a FECal Double-J stent managed at our institution and included in our series for further analysis. Based on this population, our experience, and current surgical techniques, we designed a simplified grading system to universally define the retained indwelling FECal ureteral stents.
A total of nine patients with encrusted and retained ureteral stents were identified, graded, classified, and treated at our institution. Our population consisted of five women and four men with an average age of 54.4 years and average stent indwelling time of 11.44 months. We present our novel management algorithm based on our simplified FECal stent grading system.
The management of the FECal ureteral stent represents a formidable challenge due to the need for a multimodal approach with advanced endourological techniques. Our proposed grading system and management algorithm provide a simplified and directed alternative for the surgical management dilemma of the encrusted retained ureteral stent.
Objectives
The aim of this study is to evaluate the impact of radiologist and urologist variability on detection of prostate cancer (PCa) and clinically significant prostate cancer (csPCa) with ...magnetic resonance imaging (MRI)‐transrectal ultrasound (TRUS) fusion prostate biopsies.
Patients and methods
The Prospective Loyola University MRI (PLUM) Prostate Biopsy Cohort (January 2015 to December 2020) was used to identify men receiving their first MRI and MRI/TRUS fusion biopsy for suspected PCa. Clinical, MRI and biopsy data were stratified by radiologist and urologist to evaluate variation in Prostate Imaging‐Reporting and Data System (PI‐RADS) grading, lesion number and cancer detection. Multivariable logistic regression (MVR) models and area under the curve (AUC) comparisons assessed the relative impact of individual radiologists and urologists.
Results
A total of 865 patients (469 biopsy‐naïve) were included across 5 urologists and 10 radiologists. Radiologists varied with grading 15.4% to 44.8% of patients with MRI lesions as PI‐RADS 3. PCa detection varied significantly by radiologist, from 34.5% to 66.7% (p = 0.003) for PCa and 17.2% to 50% (p = 0.001) for csPCa. Urologists' PCa diagnosis rates varied between 29.2% and 55.8% (p = 0.013) and between 24.6% and 39.8% (p = 0.36) for csPCa. After adjustment for case‐mix on MVR, a fourfold to fivefold difference in PCa detection was observed between the highest‐performing and lowest‐performing radiologist (OR 0.22, 95%CI 0.10–0.47, p < 0.001). MVR demonstrated improved AUC for any PCa and csPCa detection when controlling for radiologist variation (p = 0.017 and p = 0.038), but controlling for urologist was not significant (p = 0.22 and p = 0.086). Any PCa detection (OR 1.64, 95%CI 1.06–2.55, p = 0.03) and csPCa detection (OR 1.57, 95%CI 1.00–2.48, p = 0.05) improved over time (2018–2020 vs. 2015–2017).
Conclusions
Variability among radiologists in PI‐RADS grading is a key area for quality improvement significantly impacting the detection of PCa and csPCa. Variability for performance of MRI‐TRUS fusion prostate biopsies exists by urologist but with less impact on overall detection of csPCa.
