Prospective comparison of extracorporeal shock wave lithotripsy versus flexible ureterorenoscopy in patients with non-lower pole kidney stones under the COVID-19 pandemic.

Both shock wave lithotripsy (SWL) and flexible ureterorenoscopy (F-URS) are recommended as the first choice for non-lower pole kidney stones. Therefore, we conducted a prospective study to evaluate the efficacy, safety, and cost of SWL versus F-URS in patients with solitary non-lower pole kidney stones ≤ 20 mm under the COVID-19 pandemic. This prospective study was conducted in a tertiary hospital from June 2020 to April 2022. Patients who underwent lithotripsy (SWL or F-URS) for non-lower pole kidney stones were enrolled in this study. The stone-free rate (SFR), retreatment rate, complications, and cost were recorded. Propensity score-matched (PSM) analysis was performed. A total of 699 patients were finally included, of which 81.3% (568) were treated with SWL and 18.7% (131) underwent F-URS. After PSM, SWL showed equivalent SFR (87.9% vs. 91.1%, P = 0.323), retreatment rate (8.6% vs. 4.8%, P = 0.169), and adjunctive procedure (2.6% vs. 4.9%, P = 0.385) compared with F-URS. Complications were scarce and also comparable between SWL and F-URS (6.0% vs 7.7%, P > 0.05), while the incidence of ureteral perforation was higher in the F-URS group compared with the SWL group (1.5% vs 0%, P = 0.008). The hospital stay was significantly shorter (1 day vs 2 days, P < 0.001), and the cost was considerably less (1200 vs 30,083, P < 0.001) in the SWL group compared with the F-URS group. This prospective cohort demonstrated that SWL had equivalent efficacy with more safety and cost benefits than F-URS in treating patients with solitary non-lower pole kidney stones ≤ 20 mm. During the COVID-19 pandemic, SWL may have benefits in preserving hospital resources and limiting opportunity for virus transmission, compared to URS. These findings may guide clinical practice.

Comparative outcomes and cost of ambulatory PCNL in select kidney stone patients.

Limited hospital resources and access to care during the COVID-19 pandemic led us to implement a quality-improvement study investigating the feasibility, safety, and costs of same-day discharge after PCNL. The outcomes of 53 consecutive first-look PCNL patients included in a same-day discharge protocol during COVID-19 were compared to 54 first-look PCNL patients admitted for overnight observation. Control group had a similar comorbidity profile. Demographics, operative details, 30 day outcomes and readmissions, complications, and cost were compared between the two groups. Same-day discharge and one-day admission post-PCNL patients did not have significantly different baseline characteristics. The study group were more likely to have mini-PCNL (81% vs 50%, p < 0.01). Operative characteristics including median pre-operative stone burden (1.4 vs 1.7 cm3, p = 0.47) and post-operative stone burden (0.14 vs 0.18 cm3, p = 0.061) were similar between the two groups. Clavien-Dindo complication rates were lower in the study group compared to controls (0 vs 7%, p = 0.045). Readmission rates (2 vs 4%, p = 0.569) and ED visits (4 vs 6%, p = 0.662) were similar between the two groups. Total cost ($6,648.92 vs $9,466.07, p < 0.01) was significantly lower and operating margin ($4,475.96 vs $1,742.16, p < 0.01) was significantly higher for the same-day discharge group. Percutaneous nephrolithotomy may be performed in select patients without an increase in short-term complications, ED visits, or readmissions. Patients undergoing mini-PCNL are particularly amenable to same-day discharge, however, standard PCNL patients should not be excluded from consideration. Avoiding overnight admission decreases total cost and increased hospital operating margin.

Urological stone disease: a 5-year update of stone management using Hospital Episode Statistics.

OBJECTIVE: To reassess the trends in upper urinary tract (UUT) stone disease burden and management in the UK during the last 5 years. METHODS: The present paper is our third quinquennial analysis of trends in the management of renal stones in England. Data were collected using the Hospital Episode Statistics database for the years 2015-2020 inclusive. These were then analysed, summarized and presented. RESULTS: The number of UUT stone episodes increased by 2.2% from 86 742 in 2014-2015 to 88 632 in 2019-2020 but annual prevalence remained static at 0.14%. The number of UUT stone episodes in those of working age has remained static but increased by 9% for patients aged > 60 years (from 27 329 to 29 842). The number of shockwave lithotripsy (SWL) treatments decreased by 6.8%. There was a further increase in the use of ureteroscopy (URS) between 2015 and 2020 of 18.9%. Within this subgroup, flexible URS had the most rapid increase in use, with a rise of 20.4% from 7108 to 8558 recorded cases. Over the 20-year period from 2000 to 2020 there was a remarkable 257% increase in URS cases. There was a further decline in open surgery for UUT stone disease by 40%. Stone surgery day-case numbers have increased by 14.7% (from 31 014 to 35 566), with a corresponding decline in the number of bed days of 14.3%. Emergency cases increased by 40%, while elective cases saw a slight increase of 1.9%. CONCLUSION: The present study shows a plateauing in the prevalence of UUT stone disease in England in the last 5 years, with a move towards day-case procedures and an increase in the proportion of emergency work. For the first time in England, URS has overtaken SWL as the most common procedure for treating UUT stone disease, which might reflect patients' or physicians' preference for a more effective definitive treatment.

Stone disease in low- and middle-income countries: could augmented reality have a role in its management?

Urolithiasis is a global phenomenon. Cystolithiasis is common in parts of Africa due to low protein intake and dehydration from endemic diarrhoeal illnesses. Nephrolithiasis is less prevalent than in high-income countries, probably due to a variety of lifestyle issues, such as a more elemental diet, higher physical activity, and less obesity. Although renal stones are less common in low- and middle-income countries (LMICs), the social and economic impacts of nephrolithiasis are still considerable; many stones present late or with complications such as upper urinary tract obstruction or urosepsis. These may lead to the development of chronic kidney disease, or end-stage renal failure in a small proportion of cases, conditions for which there is very poor provision in most LMICs. Early treatment of nephrolithiasis by the least invasive method possible can, however, reduce the functional consequences of urinary stone disease. Although extracorporeal lithotripsy is uncommon, and endoscopic interventions for stone are not widespread in most of Africa, percutaneous nephrolithotomy and ureteroscopic renal surgery are viable techniques in those regional centres with infrastructure to support them. Longitudinal mentoring has been shown to be a key step in the adoption of these minimally invasive procedures by local surgeons, something that has been difficult during the coronavirus disease 2019 (COVID-19) pandemic due to travel restriction. Augmented reality (AR) technology is an alternative means of providing remote mentoring, something that has been trialled by Urolink, the MediTech Trust and other global non-governmental organisations during this period. Our preliminary experience suggests that this is a viable technique for promulgating skills in LMICs where appropriate connectivity exists to support remote communication. AR may also have long-term promise for decreasing the reliance upon short-term surgical visits to consolidate competence, thereby reducing the carbon footprint of global surgical education.

Should we support prophylactic intervention for asymptomatic kidney stones? A retrospective cohort study with long-term follow-up.

The purpose of this study was to evaluate the long-term outcomes of patients undergoing prophylactic intervention or active surveillance for asymptomatic kidney stones and identify factors influencing the outcomes. In this retrospective cohort study, we reviewed the medical records of patients with asymptomatic kidney stones in two institutes between November 2014 and November 2019. Standardized questions were asked via phone calls to supplement the outcomes. Pain, hydronephrosis, stone growth, serious infection, gross hematuria, and spontaneous passage were defined as stone-related events. Future intervention was also recorded to evaluate management. A total of 101 patients with 120 kidney units were enrolled in this study. The median follow-up time was 63 months. The patients were classified into the control group (79 cases) or exposure group (41 cases) according to whether they underwent prophylactic intervention before any stone-related events. Generally, the rates of stone-related events and future intervention were significantly different between the two groups (57.0 vs. 12.2%, p < 0.001; and 31.6 vs. 4.9%, p = 0.002, respectively). After applying stabilized inverse probability of treatment weighted, Cox regression suggested that patients who underwent prophylactic intervention were less likely to experience stone-related events and future intervention (HR = 0.175, and HR = 0.028, respectively). In conclusion, patients who underwent prophylactic intervention had a lower risk of stone-related events and future intervention, although they had some slight complications.

The effect of preoperative urine culture and bacterial species on infection after percutaneous nephrolithotomy for patients with upper urinary tract stones.

To study the relationship between preoperative urine culture, bacterial species and infection after percutaneous nephrolithotomy in patients with upper urinary tract stones, and summarize the clinical characteristics of different bacterial infections. From January 2014 and January 2020, 963 patients with upper urinary tract stones who underwent PCNL in the department of urology of Fujian provincial hospital were included in the study. Information included the patient's age, gender, weight, diabetes, chronic disease history, urine routine, preoperative urine culture results, stone size, number of stones, hydronephrosis level, operation time, body temperature, heart rate, blood pressure, breathing rate, hemoglobin, serum creatinine, bilirubin, platelets and whether there was preoperative infection were recorded. 141 patients (14.6%) had a positive urine culture before surgery, and 7 of them had multiple bacterial infections. The most common pathogenic bacteria was Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. A total of 74 cases (7.7%) of 963 patients with infection after PCNL occurred, 24 cases (32.4%) of infected patients progressed to urinary septic shock. Univariate analysis shown that the probability of infection in patients with long operation time and positive urine culture was significantly higher, and the difference was statistically significant. Further multivariate logistic regression analysis shown that positive urine culture before operation and long operation time were independent risk factors for infection after PCNL. Among the 29 patients with septic shock, 18 cases (62.1%) had a positive urine culture before surgery. The incidence (43.9%) of postoperative infection in Escherichia coli positive patients was significantly higher than that in the negative group, and the difference was statistically significant. The rate of patients with Escherichia coli infection progressing to septic shock was 9 cases (60%). 2 patients with Enterococcus faecium infection and 2 patients with Klebsiella pneumoniae infection all progressed to septic shock. The age of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 58.53 ± 11.73 years, 76.5 years and 74 years.The body temperature of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 39.10 ± 0.25 °C, 39.45 °C and 38.65 °C. The highest pct value of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 80.62 ± 31.45 ng/mL, 24.32 ng/mL and 8.45 ng/mL. The nitrite positive rate of patients with post-PCNL infection caused by Escherichia Coli, Enterococcus faecium and Klebsiella pneumoniae were 64.51%, 16.6% and 0. Postoperative infection of PCNL is significantly correlated with positive preoperative urine culture, and positive preoperative urine culture is an independent risk factor for postoperative infection. The most common pathogen of postoperative infection of PCNL is Escherichia coli, followed by Enterococcus and Klebsiella pneumoniae. Patients with Escherichia coli infection are often positive for nitrite before surgery, mainly manifested by high fever, and PCT is significantly increased (often exceeded 100 ng/ml). Enterococcus faecium and Klebsiella pneumoniae infections mostly occur in elderly patients and often progress to septic shock. Patients with Enterococcus faecium infection have a high fever, and the PCT value is significantly higher (often exceeded 20 ng/ml). Patients with Klebsiella pneumoniae infection have a moderate fever, and the PCT value generally does not exceeded 10 ng/ml. Long operation time is another independent risk factor for PCNL infection.

The Impact of Early COVID-19 Pandemic on the Presentation and Management of Urinary Calculi Across the Globe: A Systematic Review.

Introduction: It is acknowledged that the COVID-19 pandemic has had a major impact on health care services around the globe with possible worse outcomes. It has resulted in stretch of resources with canceled or delayed procedures. Patients with urinary calculi have also suffered the negative impact. This systematic review aims to assess the impact of the early COVID-19 pandemic on the presentation and management of urinary calculi around the globe. Methods: We reviewed the impact of early COVID-19 on the clinically important aspects of stone disease using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. We searched Medline, Embase, and Central databases using themes of COVID-19 OR Sars-Cov-2 OR pandemic OR coronavirus AND kidney stone, urinary calculi, urolithiasis, and similar allied terms. Inclusion criteria were studies with data on both pre- and COVID-19 period covering one or more of eight clinical domains. Results: Our search returned 231 studies, after removal of duplicates, of which 18 studies were included for analysis. The number of patients presenting to hospital declined by 21%-70% at the beginning of the pandemic, whereas majority of studies reported increased associated complications. There are mixed reports in terms of delay to presentation and use of conservative management. There was a consistent trend toward reduction in elective procedures with wide variations (shockwave lithotripsy 38%-98%, percutaneous nephrolithotomy 94%-100%, and ureteroscopy 8%-98%). There was a trend toward increased nephrostomy insertion with the onset of the pandemic. Conclusion: This review demonstrated the differences in the number of patients presenting to hospital, complication rates, and management of urinary calculi, including surgical interventions, with the onset of the COVID-19 pandemic. It offers baseline global information that would help understand the impact of early pandemic, variations in practices, and be useful for future comparisons.

Global Web Trends Analysis of Minimally Invasive Urinary Stone Treatment in the Last Decade and During the COVID-19 Pandemic.

With the rising incidence of urinary stone disease, web searches for stone treatments are increasing. Google Trends (GT) data for a 10-year period and during the coronavirus disease 2019 (COVID-19) pandemic were used to investigate the trend variations for the most popular minimally invasive stone therapies based on time and region. GT can create a line graph that shows how interest in various territories has risen or decreased over time. Search terms were generated for extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), ureterorenoscopy (URS), and laparoscopic pyelolithotomy/ureterolithotomy. Using the "global" inquiry category, the data were included "worldwide" from January 1, 2009 to December 31, 2021. In recent years, Google and YouTube searches for total minimally invasive stone treatments have increased. RIRS, URS, and PCNL trends revealed a substantial rise in the regression analysis (p < 0.05), but SWL trends showed a significant reduction (p < 0.05). RIRS was the main intervention with interest growing most over time. Web searches for stone treatments decreased in the first period of the COVID-19 pandemic. To a rising degree of involvement, patients and physicians from all over the world utilize the internet to search for minimally invasive stone operations. RIRS, URS, and PCNL are becoming more popular in web trends and SWL still has the highest trend despite the decline in popularity recently. The number of trustworthy web-based tools about stone treatments should be increased, and patients and physicians should be directed to these sources.

Consensus Statement on Urinary Stone Treatment During a Pandemic: A Delphi Process from the Endourological Society TOWER Research Initiative.

Introduction: The novel coronavirus disease (COVID-19) pandemic has had a significant impact on the care of patients with urolithiasis. Recommendations and prioritization of endourologic surgical procedures vary among regions, and a comprehensive overall international directive is needed. We used the Delphi method to obtain international consensus on managing urolithiasis patients during the pandemic. Methods: A three-round Delphi process was used to elicit expert consensus (53 global key opinion leaders within the Endourological Society from 36 countries) on an extensive survey on management of endourologic patients in a pandemic. Questions addressed general management, inpatient and outpatient procedures, clinic visits, follow-up care, and best practices for suspension and resumption of routine care. Results: Consensus was achieved in 64/84 (76%) questions. Key consensus findings included the following: consultations should be delivered remotely when possible. Invasive surgical procedures for urolithiasis patients should be reserved for high-risk situations (infection, renal failure, etc.). To prevent aerosolization, spinal anesthesia is preferred over general, whenever feasible. Treatment of asymptomatic renal stones should be deferred. Primary definitive treatment of obstructing or symptomatic stones (both renal and ureteral) is preferred over temporizing drainage. Extracorporeal shockwave lithotripsy should be continued for obstructive ureteral stones. There was consensus on treatment modalities and drainage strategies depending on location and size of the stone. Conclusion: International endourologist members of the Endourological Society participated in this Delphi initiative to provide expert consensus on management of urolithiasis during a pandemic. These results can be applied currently and during a future pandemic.

Ambulatory Percutaneous Nephrolithotomy May Be Cost-Effective Compared to Standard Percutaneous Nephrolithotomy.

Background: Coronavirus disease 2019 (COVID-19) changed the practice of medicine in America. During the March 2020 lockdown, elective cases were canceled to conserve hospital beds/resources resulting in financial losses for health systems and delayed surgical care. Ambulatory percutaneous nephrolithotomy (aPCNL) has been shown to be safe and could be a strategy to ensure patients receive care that has been delayed, conserve hospital resources, and maximize cost-effectiveness. We aimed to compare the safety and cost-effectiveness of patients undergoing aPCNL against standard PCNL (sPCNL). Materials and Methods: Ninty-eight patients underwent PCNL at Indiana University Methodist Hospital, a tertiary referral center, by three expert surgeons from January 2020 to September 2020. The primary outcome of the study was to compare the 30-day rates of emergency department (ED) visits, readmissions, and complications between sPCNL and aPCNL. Secondary outcomes included cost analysis and stone-free rates (SFRs). Propensity score matching was performed to ensure the groups were balanced. Statistical analyses were performed using SAS 9.4 using independent t-tests for continuous variables and chi-square analyses for categorical variables. Results: Ninety-eight patients underwent PCNL during the study period (sPCNL = 75 and aPCNL = 23). After propensity score matching, 42 patients were available for comparison (sPCNL = 19 and aPCNL = 23). We found no difference in 30-day ED visits, readmissions, or complications between the two groups. aPCNL resulted in cost savings of $5327 ± 442 per case. SFRs were higher for aPCNL compared with sPCNL. Conclusions: aPCNL appears safe to perform and does not have a higher rate of ED visits or readmissions compared with sPCNL. aPCNL may also be cost-effective compared with sPCNL.

Effects of COVID-19 pandemics on urinary metabolites in kidney stone patients: our kidney stone prevention clinic experience.

BACKGROUND: The dietary habits and lifestyle changes during the COVID-19 pandemic could affect the urinary risk factors in kidney stone formers. In this study, we investigated the effects of the COVID-19 pandemic on 24-h urine metabolites, as a surrogate for dietary intake, in patients with kidney stones, in Tehran, Iran. METHODS: We evaluated the medical records of all patients with urolithiasis who visited in our stone prevention clinic from the beginning of COVID-19 in Iran to 1 year later (Feb 2020-Feb 2021) and compared it with the patients' medical records in the same period a year before COVID-19 (Feb 2019-Feb 2020). RESULTS: The results of our stone prevention clinic showed a decrease in the number of visits during COVID-19. Twenty-four-hour urine urea, sodium, and potassium were significantly lower, and 24-h urine magnesium was significantly higher during COVID-19. Higher 24-h urine oxalate was only shown in patients with the first-time visit, whereas lower 24-h urine uric acid and citrate were only shown in patients with the follow-up visits. CONCLUSIONS: COVID-19 pandemics may change some of the dietary habits of the patients, including lower salt, protein, and fruit and vegetable intake. Although economic issues, restricted access, or sanitation issues may be the reason for the undesirable dietary changes, the importance of a quality diet should be discussed with all patients, as possible. Since the number of patients visited in the stone clinic was lower during COVID-19, virtual visits could be an excellent alternative to motivate patients with kidney stones.

Efficacy and safety of the EMS Swiss LithoClast® Trilogy for PCNL: results of the European multicentre prospective study on behalf of European Section of UroTechnology.

PURPOSE: PCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm2/min) and using the 3D calculated stone volume (526.7 mm3/min). METHODS: Ten European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1-10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1-10 scale (10 = extremely effective). RESULTS: One hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13-84 years). Mean stone clearance rate was 65.55 mm2/min or 945 mm3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien-Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite. CONCLUSIONS: We have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

Care and prevention during the COVID-19 pandemic quarantine: sedentary lifestyle and increased risk of kidney stones.

Currently, the issue of lifestyle combined with lack of physical activity in quarantine conditions during the COVID-19 pandemic has become a major health problem in many countries around the world. Increased inactivity is associated with increased obesity as well as decreased physical activity and general health. Kidney stones are the third most common urinary tract disease. Prevention of non-communicable diseases depends on controlling risk factors such as low levels of physical activity. Kidney stones are also among the noncommunicable diseases that can be prevented by changing behavioral habits. Physical activity is a behavior that has many proven health benefits and is one of the most effective ways to prevent chronic diseases. The aim of this study was to investigate sedentary lifestyle and its relationship with oxidative stress and kidney stone formation, and finally to provide medical solutions and recommendations.

Postoperative Analgesic Efficiency of Quadratus Lumborum Block Iii Versus Peritubal Local Infiltration in Patients Undergoing Percutaneous Nephrolithotomy Operation: A Randomized Comparative Trial (preprint)

Background: The postoperative pain after percutaneous nephrolithotomy (PCNL) can be managed by many peripheral blocks techniques (e.g., paravertebral and quadrates lumborum block), and local anesthesia infiltration. Therefore, this prospective study was conducted to evaluate the effect of quadratus lumborum type III versus peritubal local infiltrating on postoperative analgesia for patients undergoing PCNL under general anesthesia.Methods: Eligible subjects after exclusion of COVID-19 patients, with renal stones less than 2 cm undergoing PCNL surgery under general anesthesia. Exclusion criteria were: 21<years of age or > 60 years of age; bleeding disorders; allergies to local anesthetics; psychiatric patients; and American Society of Anesthesia (ASA) physical status III and IV. Eighty patients were randomly allocated to 2 equal groups. In the Quadratus group, participant received 20 mL of bupivacaine 0.25% in the fascial plane between the quadratus lumborum and Psoas muscle; and in the peritubal group, patients received 10 mL of bupivacaine 0.25% around the nephrostomy tube at 6 and 12 o’clock positions (total 20 mL). The quadratus lumborum block and peritubal infiltration were performed by the primary investigator and the urologist, respectively. All patients received standard postoperative analgesia (paracetamol, ketorolac, and morphine via patient-controlled analgesia. Both patients and Data collecting staff were blinded to study group. Primary outcome was the visual analogue score at rest and on coughing or movement at 2, 4, 6, 12, and 24 hours. Secondary outcomes were 24 hours total morphine consumption, 1st use of morphine pump, incidence of side effects (pruritis and nausea and vomiting) and patient satisfaction.Results: Data were analyzed from 78 patients (39 patients in each group). The mean resting VAS score in quadratus group at 6 and 12 hours was (3), while the mean VAS in peritubal group was (5) and (6) at 6 and 12 hours, respectively. Dynamic VAS score in peritubal group at 6 hours was (mean 6) with p<0.0001 when compared to resting value. The 24 hours’ morphine consumption was 8.5-11mg and 16-19 mg, in quadratus and peritubal group, respectively (the difference in mean of 9 at the 95% confidence interval; p<0.0001). patients start to use morphine pump after 121.4 min and 180.2 min in group peritubal and quadratus, respectively. Patients in group quadratus were statistically more satisfied, in both groups incidence of complication was low.Conclusion: Quadratus Lumborum block was more effective than Peritubal LA infiltration regarding postoperative VAS score both at rest and during movement with lower postoperative morphine consumption and more satisfaction in patients undergoing PCNL surgery.