Consultation on UTUC II Stockholm 2022: diagnostics, prognostication, and follow-up-where are we today?

PURPOSE: To summarise the current knowledge regarding diagnostics, prognostication and follow-up in upper tract urothelial carcinoma (UTUC). METHODS: A scoping review combined with expert opinion was applied to provide an overview of the current research field. Based on the published literature and the experts' own experience and opinions, consensus was reached through presentations and discussions at the meeting Consultation on UTUC II in Stockholm 2022. RESULTS: The strongest prognostic factors in UTUC are tumour grade and stage. They are correlated, and grade is used for indirect staging. The diagnostic examinations should include multiphase computed tomography urography (CTU) with corticomedullary phase, and urethrocystoscopy with cytology. If there is no clear diagnosis for clinical decision-making, ureterorenoscopy (URS) with focal cytology and biopsies should be performed. Both WHO classification systems (1973/1999 and 2004/2016) should be used. Novel biomarker tests are not yet widespread nor recommended for the detection of UTUC. Long-term, regular follow-up, including URS in patients who have had organ-sparing treatment, is important to check for tumour recurrences, intravesical recurrences, metastases and progression of the tumour. CONCLUSION: Proper diagnostics with correct grading of UTUC are necessary for appropriate treatment decisions. The diagnostics should include CTU with corticomedullary phase, urine or bladder cytology, URS with focal barbotage cytology, and biopsies when needed for proper diagnosis and risk stratification. Regular, long-term follow-ups are fundamental, due to the high rate of recurrence and risk of progression.

The Endourological Society Inaugural Census Report.

The Endourological Society, the premier urologic society encompassing endourology, robotics, and focal surgery, is composed of a diverse group of >1300 urologists. However, limited information has been collected about society members. Recognizing this need, a survey was initiated to capture data regarding current member practices, as well as help the Society shape the future direction of the organization. Presented herein is the inaugural Endourological Society census report as the beginning of a continued effort for global improvement in the field of endourology. Using a REDCap® database, an email survey was circulated to the membership of the Endourological Society from May through June 2021. Twenty questions were posed, categorizing member data in terms of epidemiology/demographics, practice patterns, member opinions, and future educational preferences. Responses were received from 534 members, representing 40.3% of membership. Data demonstrated that the average age, gender, race, and ethnicity of the typical Society member respondent is a 48-year-old Caucasian male working in the United States, with a mean of 25 years in practice. Retrograde endoscopy and percutaneous nephrolithotomy were identified as the most common practice skills, and 50% of members are involved in robotics. Importantly, the census confirmed that the World Congress of Endourology and Technology remains popular with Society members as a means of educational advancement. To sustain and advance the Society, information is required to understand the career interests and future educational desires of its members. This inaugural census provides crucial data regarding its membership and how the Society can achieve continued success and adjust its focus. Future census efforts will expand on the initial findings and stratify the data to elucidate changes in the needs of the Society as a whole. Circulating an annual census will allow for continued improvements in the field of endourology and, ultimately, better care for urologic patients.

Cystinuria: clinical practice recommendation.

Cystinuria (OMIM 220100) is an autosomal recessive hereditary disorder in which high urinary cystine excretion leads to the formation of cystine stones because of the low solubility of cystine at normal urinary pH. We developed clinical practice recommendation for diagnosis, surgical and medical treatment, and follow-up of patients with cystinuria. Elaboration of these clinical practice recommendations spanned from June 2018 to December 2019 with a consensus conference in January 2019. Selected topic areas were chosen by the co-chairs of the conference. Working groups focusing on specific topics were formed. Group members performed systematic literature review using MEDLINE, drafted the statements, and discussed them. They included geneticists, medical biochemists, pediatric and adult nephrologists, pediatric and adult urologists experts in cystinuria, and the Metabolic Nephropathy Joint Working Group of the European Reference Network for Rare Kidney Diseases (ERKNet) and eUROGEN members. Overall 20 statements were produced to provide guidance on diagnosis, genetic analysis, imaging techniques, surgical treatment (indication and modalities), conservative treatment (hydration, dietetic, alkalinization, and cystine-binding drugs), follow-up, self-monitoring, complications (renal failure and hypertension), and impact on quality of life. Because of the rarity of the disease and the poor level of evidence in the literature, these statements could not be graded. This clinical practice recommendation provides guidance on all aspects of the management of both adults and children with cystinuria, including diagnosis, surgery, and medical treatment.

Non-contrast computed tomography characteristics in a large cohort of cystinuria patients.

PURPOSE: Cystine stones are widely considered hard and difficult to treat. Hounsfield Units (HU) are used in other stone types to estimate 'hardness' and treatments based on that finding. Our objective was to report mean HU of cystine stones in vivo in a large case series of cystinuria patients and assess for differences in genotype. METHODS: A prospective case series of cystinuria patients referred to a specialist centre was analysed. CT imaging was assessed by two independent radiologists to determine in vivo attenuation of cystine calculi. Mean HU was compared for both cystinuria genes (SLC3A1 and SLC7A9) using an independent t-test. RESULTS: 164 adult cystinuric patients were identified (55% male), median age 43 years (range 18-80). Median follow up was 31 months (IQR 10-62). Genetic data available for 153/164 (93%) demonstrated 97 SLC3A1 (63%) and 55 (36%) SLC7A9 mutations (39 homozygous, 16 heterozygous) and one heterozygous for both SLC3A1/SLC7A9. 107 patients had CT images available demonstrating calculi. Median HU across the cohort was 633 (5th to 95th centile 328-780). There was no difference in mean HU between SLC3A1 and SLC7A9 genotypes (p = 0.68) or homo and heterozygous SLC7A9 (p = 0.70). Mean HU correlated with stone size (Pearson correlation coefficient = 0.51, p < 0.001). CONCLUSION: In this large single centre cystinuria cohort, mean HU was low for stones that are difficult to treat. Calculi of < 800 HU should prompt consideration of a cystinuria diagnosis. Attenuation was not associated with genotype, and distinct 'smooth' and 'rough' stones were not observed. Calculi with HU > 1000 are unlikely pure cystine, and in a known cystinuric would suggest conversion to another stone type.

Consultation on kidney stones, Copenhagen 2019: aspects of intracorporeal lithotripsy in flexible ureterorenoscopy.

PURPOSE: To summarize current knowledge on intracorporeal laser lithotripsy in flexible ureterorenoscopy (fURS), regarding basics of laser lithotripsy, technical aspects, stone clearance, lithotripsy strategies, laser technologies, endoscopes, and safety. METHODS: A scoping review approach was applied to search literature in PubMed, EMBASE, and Web of Science. Consensus was reached through discussions at the Consultation on Kidney Stones held in September 2019 in Copenhagen, Denmark. RESULTS AND CONCLUSIONS: Lasers are widely used for lithotripsy during fURS. The Holmium laser is still the predominant technology, and specific settings for dusting and fragmenting have evolved, which has expanded the role of fURS in stone management. Pulse modulation can increase stone ablation efficacy, possibly by minimizing stone retropulsion. Thulium fibre laser was recently introduced, and this technology may improve laser lithotripsy efficiency. Small fibres give better irrigation, accessibility, and efficiency. To achieve optimal results, laser settings should be adjusted for the individual stone. There is no consensus whether the fragmentation and basketing strategy is preferable to the dusting strategy for increasing stone-free rate. On the contrary, different stone scenarios call for different lithotripsy approaches. Furthermore, for large stone burdens, all laser settings and lithotripsy strategies must be applied to achieve optimal results. Technology for removing dust from the kidney should be in focus in future research and development. Safety concerns about fURS laser lithotripsy include high intrarenal pressures and temperatures, and measures to reduce both those aspects must be taken to avoid complications. Technology to control these parameters should be targeted in further studies.

Development and content validation of the percutaneous nephrolithotomy assessment score.

OBJECTIVES: To develop and content validate a percutaneous nephrolithotomy assessment score, taking into consideration the procedure-specific risks. METHODS: This prospective international study utilized the Healthcare Failure Mode and Effect Analysis to systematically outline percutaneous nephrolithotomy and failure modes for each step. A total of 25 h was spent observing percutaneous nephrolithotomy carried out by six expert surgeons. Hazard analysis scoring was carried out by 11 experts. It was determined if the steps were single point weaknesses. Single point weaknesses and those assigned a hazard score ≥4 were included in the percutaneous nephrolithotomy assessment score. The tool was then content validated by 16 experts from 10 countries. RESULTS: Application of the Healthcare Failure Mode and Effect Analysis identified 64 failure modes; 37 failure modes had a hazard score ≥4. After adaptations based on expert feedback the final percutaneous nephrolithotomy assessment score was developed containing 10 phases, 21 processes and 47 subprocesses. All participants agreed that the tool contained pertinent procedural steps. CONCLUSIONS: This study has developed and shown the international content validity of a novel percutaneous nephrolithotomy assessment score. The tool can be utilized in modular operating room training to quantify operator progress, and can be used in conjunction with other modules as part of a complete percutaneous nephrolithotomy curriculum for trainees.

Medical Expulsive Therapy for Urinary Stones: Future Trends and Knowledge Gaps.

CONTEXT: Medical expulsive therapy (MET) for ureteral stones has become a controversial area due to the contradictory results of high-quality trials and meta-analyses. OBJECTIVE: We aimed to review the literature to evaluate the value of and future directions for MET for ureteral stone disease. EVIDENCE ACQUISITION: A literature search of the MEDLINE database and the Cochrane Library was conducted to collect articles about MET for ureteral calculi published up to 28 October 2018. A total of 524 articles were screened. Sixty-nine publications that met the inclusion criteria for this review were chosen. Among the primary research articles on MET with stone clearance as the primary outcome, seven responded to high-quality requirements of Cochrane Collaboration's tool for assessing the risk of bias in randomised trials. EVIDENCE SYNTHESIS: The vast majority of randomised, double-blind, placebo-controlled trials without a high or an unclear risk of bias did not find a benefit of MET for increased ureteral stone passage rates. This is in contrast to results of meta-analyses that are skewed by low-quality trials. CONCLUSIONS: The strength of evidence for the benefit of MET in ureteral stones is low, even for distal ureteral stones >5 mm. In the absence of further high-quality data, individual clinicians are required to decide for themselves whether to believe high-quality single trials or meta-analyses. PATIENT SUMMARY: We evaluated the value of and future directions for medical expulsive therapy (MET) for ureteral stone disease. We found that outcomes varied between studies. Individual clinicians are required to decide for themselves which studies to believe. Alpha-blockers as MET may retain a role in a selective group of well-counselled patients with larger stones who understand the side effects and off-label use.

Hypertension and renal impairment in patients with cystinuria: findings from a specialist cystinuria centre.

Higher blood pressures (mean systolic difference 16.8 mmHg) when compared to matched individuals are already reported in patients with calcium urolithiasis. We present the prevalence of hypertension and renal impairment in patients with cystinuria from our specialist single centre. We analysed our prospective database of adult patients with cystinuria who attend our cystinuria service. This included details of the medical and operative management of their disease. Descriptive statistics were used to analyse and present the data. 120 patients were included with a median age of 40 (19-76) years, 66 were male (55%) and 54 were female (45%). 54/120 patients (45%) were taking medications to prevent stone formation. 78% (94/120) patients reported having undergone one or more stone-related procedure. 59% (55/94) of these having required at least one PCNL or open procedure during their lifetime. Prevalence of hypertension was 50.8% (61/120), and double in males compared to females (62.1% vs. 37.0%, P = 0.0063). Mean baseline creatinine was 88.2 (49-153) µmol/l and eGFR was 77.6 (32-127) ml/min/1.73 m2. When categorized by CKD stage, only 24.6% (27% vs. 21%, M vs. F) patients had normal renal function (being an eGFR > 89 ml/min/1.73 m2). 57.6% patients were CKD stage 2 and 17.8% CKD stage 3. Females had a slightly greater incidence of renal impairment. All patients who have previously undergone a nephrectomy (n = 10) or have a poorly functioning kidney (n = 19) have renal impairment (CKD stage 2 or 3). Incidence of hypertension in patients with cystinuria is 51%, with a male preponderance. Only 25% of patients with cystinuria have normal renal function. This highlights the long-term cardiovascular and renal risks that the metabolic effects of cystinuria pose, in addition to the challenges of managing recurrent urolithiasis in a young population.

Dusting, fragmenting, popcorning or dustmenting?

PURPOSE OF REVIEW: The present review identifies the latest scientific investigations within the fields of fragmenting and dusting to discuss optimizing treatment. In addition, new settings such as 'popcorning' are scrutinized carefully. RECENT FINDINGS: During the past years, endoscopic techniques have continuously developed and changed the management of the treatment of kidney stones using ureteroscopy (URS). The most currently used energy source for stone disintegration is holmium laser lithotripsy. This technique offers different options for the surgeons to treat their patients suffering from kidney stones. SUMMARY: URS with the holmium laser allows surgeons to use a variety of different strategies for treating urinary stones. There are two techniques which are most frequently used within this field: firstly fragmenting, using low frequencies and high pulse energy to break stones into small fragments before removal. On the other hand, dusting has been popularized in the field of endourology in recent years. This uses high frequencies and low pulse energy to form fine dust particles which then pass spontaneously down the ureter.

Learning Curves in Urolithiasis Surgery: A Systematic Review.

BACKGROUND AND AIMS: Procedures for urolithiasis are a core part of the development for the urologist in training. Understanding the learning curve of the procedures is important, allowing for planning in the training and assessment of trainees. The aim of this study was to systematically review the literature pertaining to learning curves in urolithiasis surgery. MATERIALS AND METHODS: The review was registered on the PROSPERO database and conducted in keeping with the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement. Embase, MEDLINE, and PsycINFO were systematically searched from inception to January 2018, with a reference review conducted. All empirical studies on learning curves in urolithiasis surgery were included irrespective of procedure. Articles describing pediatric surgery, nontechnical skills in surgery, or those not written in English were excluded. RESULTS: Of 390 articles identified from screening, a final 18 studies were included. Fourteen studies identified the learning curve in percutaneous nephrolithotomy. These studies identified a learning curve of between 30 and 60 cases for both operative time (OT) and complication rates. Four articles focused on flexible ureteroscopy (FURS); the learning curve for FURS has been outlined as 60 cases for OT and 56 cases for fragmentation efficacy. CONCLUSIONS: The complexities of determining learning curves are extensive; studies use different parameters to measure outcomes and observe skill acquisition rates of surgeons with differing prior experience. Evidence in this article can guide trainee urologists with regard to the expected rate of progress. Multi-operator multicenter research utilizing standard outcome measures should be conducted to establish definitive learning curves.