A diagnostic-therapeutic pathway for patients with kidney stone disease: 2020 update / Percorso diagnostico-terapeutico per il paziente con calcolosi renale: update 2020

The natural history of urinary kidney stone disease includes the risk of relapses and can be associated with the risk of chronic kidney disease, bone and cardiovascular disease. For this reason, a wide clinical-metabolic assessment of the kidney stone patient is of great importance since the first presentation of the stone, to set an appropriate preventive treatment. The proposed diagnostic-therapeutic pathway includes a careful medical history, in order to highlight a secondary kidney stone disease and the main risk factors for kidney stones, chronic renal disease, or cardiovascular and bone disease; a metabolic evaluation on multiple levels, according to the severity of the disease, and the presence or absence of risk factors, and appropriate instrumental investigations. Thus, the information collected makes it possible to set a preventive treatment consisting of general rules and, if necessary, specific pharmacological or nutritional interventions. This paper has been prepared by the Italian Multidisciplinary Study Group for Kidney Stone Disease, and it is addressed to the several professional figures involved in the management of patients suffering from nephrolithiasis, from the emergency doctor to the general practitioner, urologist, nephrologist, radiologist, and dietician. A diagnostic-therapeutic pathway for patients with kidney stone disease was first published on this Journal in 2010. The present contribution aims at amending and updating the article published exactly ten years ago, to serve as an easy-to-use reference and to guide good clinical practice in this field.

Changes in renal papillary density after hydration therapy in calcium stone formers.

BACKGROUND: Previous studies have shown that, compared with non-stone formers, stone formers have a higher papillary density measured with computer tomography (CT) scan. The effect of increased hydration on such papillary density in idiopathic calcium stone formers is not known. METHODS: Patients with recurrent calcium oxalate stones undergoing endourological procedures for renal stones at our Institution from June 2013 to June 2014 were considered eligible for enrolment. Enrolled patients underwent a baseline unenhanced CT scan before the urological procedure; after endoscopic removal of their stones, the patients were instructed to drink at least 2 L/day of a hypotonic, oligomineral water low in sodium and minerals (fixed residue at 180 °C < 200 mg/L) for at least 12 months. Finally, the patients underwent a follow-up unenhanced CT scan during hydration regimen. RESULTS: Twenty-five patients were prospectively enrolled and underwent baseline and follow-up CT scans. At baseline, mean papillary density was 43.2 ± 6.6 Hounsfield Units (HU) (43.2 ± 6.7 for the left kidney and 42.8 ± 7.1 HU for the right kidney). At follow-up and after at least 12 months of hydration regimen, mean papillary density was significantly reduced at 35.4 ± 4.2 HU (35.8 ± 5.0 for the left kidney and 35.1 ± 4.2 HU for the right kidney); the mean difference between baseline and follow-up was - 7.8 HU (95% confidence interval - 10.6 to - 5.1 HU, p < 0.001). CONCLUSIONS: Increased fluid intake in patients with recurrent calcium oxalate stones was associated with a significant reduction in renal papillary density. TRIAL REGISTRATION: NCT03343743 , 15/11/2017 (Retrospectively registered).

Bilateral Ureteral Stent Removal after 15 Years: A Case Report.

We present the first reported case of a patient with a forgotten ureteral stent. A 68-year-old woman had undergone radical hysterectomy for cervical cancer in 1997, at which time bilateral ureteral stents were placed. She was admitted to our hospital with stranguria, dysuria, and lower back pain of 10 days duration. Preoperative radiologic evaluation revealed the presence of ureteral stents, which had been in place since 1997. With the patient under general anesthesia, the bilateral stents were removed by urethral cystoscopy. No stone formation was noted. The procedure was easy and fast, and no intraoperative complications occurred.

The Risk of Chronic Kidney Disease Associated with Urolithiasis and its Urological Treatments: A Review.

PURPOSE: Urolithiasis can impair kidney function. This literature review focuses on the risk of kidney impairment in stone formers, the specific conditions associated with this risk and the impact of urological surgery. MATERIALS AND METHODS: The PubMed® and Embase® databases were searched for publications on urolithiasis, its treatment, and the risk of chronic kidney disease, end stage renal disease and nephrectomy in stone formers. RESULTS: In general, renal stone formers have twice the risk of chronic kidney disease or end stage renal disease, and for female and overweight stone formers the risk is even higher. Patients with frequent urinary tract infections, struvite stones, urinary malformations and diversions, malabsorptive bowel conditions and some monogenic disorders are at high risk for chronic kidney disease/end stage renal disease. Shock wave lithotripsy or minimally invasive urological interventions for stones do not adversely affect renal function. Declines in renal function generally occur in patients with preexisting chronic kidney disease or a large stone burden requiring repeated and/or complex surgery. CONCLUSIONS: Although the effect size is modest, urolithiasis may cause chronic kidney disease and, thus, it is mandatory to assess patients with renal stones for the risk of chronic kidney disease/end stage renal disease. We suggest that all guidelines dealing with renal stone disease should include assessment of this risk.

Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature.

BACKGROUND: Nephrolithiasis is a frequent condition. While it is generally accepted that such condition carries a risk of recurrence over time, the exact risk and its predictors have been rarely quantitated. We aimed to estimate recurrence of kidney stones, overall and in specific subgroups, from randomized controlled trials (RCTs) of calcium stone formers. METHODS: Systematic review of RCTs of adult patients with idiopathic calcium kidney stones. Recurrence rates analyzed in subgroups based on type of intervention and other characteristics, using Poisson regression models. RESULTS: The analysis included 21 RCTs with 2168 participants over a median follow-up of 3.2 years (range 0.5-9.7). The median recurrence of kidney stones was 15 per 100 person-years (range 0-110). Recurrence was higher in those with two or more previous stone episodes compared to those with a single episode at enrolment (16 vs. 6 per 100 person-years, p < 0.001) and in those untreated or treated with dietary changes compared to those treated with drugs (26 vs. 23 vs. 9 per 100 person-years, p < 0.001). The effect of drugs on recurrence seemed to be beneficial only among those with two or more previous stone episodes. CONCLUSIONS: The overall recurrence rate of stones depends on factors such as previous stone history and type of treatment. Dietary approaches seem to be more effective among single stone formers, whereas drugs seem to be more effective among recurrent stone formers.

Neutrophil gelatinase-associated lipocalin (NGAL) value changes before and after shock wave lithotripsy.

Our aim was to determine short and medium-term changes of neutrophil gelatinase-associated lipocalin (NGAL) in the urine of patients undergoing shock wave lithotripsy (SWL). In patients with kidney stones, serum urea and creatinine (Cr), urine Cr and NGAL levels were determined immediately before and at 3, 24 h and 30 days after SWL. Urine NGAL concentrations were normalized to urinary Cr ruling out the confounding effect of variable hydration states. Thirty-five patients with a single renal stone were enrolled. Inclusion criteria were: first SWL treatment for each patient, single radiopaque renal stone <20 mm; normal renal function. Exclusion criteria were: body mass index (BMI) > 30 kg/m2, recent episodes of renal colic (less than 3 months), the presence of radiolucent stones, renal impairment, upper urinary tract obstruction or malignancy, acute pyelonephritis, patients who consumed potentially nephrotoxic drugs within 4 weeks before the evaluation. Geometric means of urinary NGAL/Cr ratio measured 3 h after SWL were significantly higher than baseline values (difference 7.56 ng/mg, 95% confidence interval 1.61, 13.51; p value = 0.013). No changes were found for urinary NGAL/Cr measured at 24 h (p value = 0.92) and at 30 days (p value = 0.13) after SWL compared with baseline values. Urinary NGAL levels increase soon after SWL (3 h) and quickly return to and maintain basal levels (1 and 30 days). Further studies are necessary to understand the hypothetical role of NGAL as a guide to the degree of tissue injury after SWL.

Penile curvature: an update for management from 20 years experience in a high volume centre.

Our aim was to review the literature and discuss about penile curvature in order to have an update for management after 20 years experience in the field.Penile curvature may be congenital or acquired. Congenital penile curvature is a relatively uncommon condition that may present in late adolescent or early adult life. The incidence is estimated to be 0.6 %. On the other side, acquired penile curvature has an overall prevalence of 0.5-13%. Three main factors seem to increase the risk of developing an acquired penile curvature, often related to Peyronie's disease: penile traumatism, genetic and familiar conditions and a history of diseases of the genital tract. In treating Peyronie's disease, no medical therapy is fully effective, and surgery remains the gold standard in cases of severe deformity and/or erectile disfunction. Peyronie's disease is associated with significant psychological stress for patients and their partners. Appropriate treatment should be individualized and tailored to the patient's goals and expectations. There is not the 'best' surgical technique and outcomes are satisfactory when proper treatment decisions are made.

Postoperative infection rates in patients with a negative baseline urine culture undergoing ureteroscopic stone removal: a matched case-control analysis on antibiotic prophylaxis from the CROES URS global study.

PURPOSE: To examine the effects of antibiotic prophylaxis on postoperative infection rate in patients with negative urine cultures undergoing ureteroscopy (URS). PATIENTS AND METHODS: Using the Clinical Research Office of the Endourological Society (CROES) URS Global Study database, patients with a negative baseline urine culture undergoing URS for ureteral stones (n=1141) or kidney stones (n=184) not receiving antibiotic prophylaxis were matched with those who were predefined by risk factors, including gender, American Society of Anesthesiologists (ASA) score, and ureteral stent placement. Patient characteristics, operative data, and postoperative outcomes, including the development of urinary tract infection (UTI) and fever, in the two groups were compared. RESULTS: Antibiotic prophylaxis use differed widely across participating countries (13%-100%). Differences were found between patients who did or did not receive antibiotic prophylaxis regarding the frequency of anticoagulation medication, previous treatment with URS, stone burden, previous presence of kidney stones, duration of current URS, and complications post-URS. The prevalence of fever and UTI was low (≤2.2%) and similar in both groups. Factors predictive of postoperative UTI or fever were female gender, Crohn's and cardiovascular disease, a high stone burden, and an ASA score of II or higher. CONCLUSIONS: In patients with a negative baseline urine culture undergoing URS for ureteral or renal stones, rates of postoperative UTI and fever were not reduced by preoperative antibiotic prophylaxis. Female gender and a high ASA score were specific risk factors for postoperative infection in this patient group.

Randall's plaques, plugs and the clinical workup of the renal stone patient.

Renal stone patients are generally considered to be affected with the idiopathic form of calcium nephrolithiasis. It is debated whether a comprehensive diagnostic evaluation should be performed in first stone patients. There is a substantial number of first or mildly recurrent stone formers who do not undergo any work-up to investigate stone etiology and in whom stone etiology is unknown. In this setting, the endourological approach can provide the treating physician with diagnostic information based on the presence of Randall's plaques and/or ductal plugs, thus triggering the need for further clinical investigations.

FT-IR analysis of urinary stones: a helpful tool for clinician comparison with the chemical spot test.

BACKGROUND: Kidney stones are a common illness with multifactorial etiopathogenesis. The determination of crystalline and molecular composition and the quantification of all stone components are important to establish the etiology of stones disease but it is often laborious to obtain using the chemical method. The aim of this paper is to compare chemical spot test with FT-IR spectroscopy, for a possible introduction in our laboratory. METHODS: We analyzed 48 calculi using Urinary Calculi Analysis kit in accordance with the manufacturer's instructions. The same samples were analyzed by FT-IR using the Perkin Elmer Spectrum One FT-IR Spectrometer. All FT-IR spectra of kidney stones were then computer matched against a library of spectra to generate a report on the various components. RESULTS: On the basis of FT-IR analysis, the 48 calculi were divided into three groups: pure stone, mixed stone, and pure stone with substances in trace. Results of each group were compared with those obtained with chemical spot test. A general disagreement between methods was observed. CONCLUSIONS: According to our data, the introduction of the FT-IR technique in clinical chemistry laboratory may be more responsive to clinician expectations.

OnabotulinumtoxinA injection therapy in men with LUTS due to primary bladder-neck dysfunction: objective and patient-reported outcomes.

OBJECTIVE: To determine efficacy and safety of OnabotulinumtoxinA (BoNT-A) injection therapy in medically refractory patients with lower urinary tract symptoms (LUTS) due to primary bladder-neck dysfunction (PBND). MATERIALS AND METHODS: Thirty-five consecutive ambulatory males diagnosed with PBND and refractory to medical therapy, with IPSS > 15, Qmax < 15 ml/sec, and total prostate volume < 30 cm(3), were screened from January 2010 to December 2011. Eligible patients underwent transurethral bladder-neck injection of BoNT-A (200 U, 50 U/ml × 4 sites) and were assessed at baseline, 2-, 6-, 9-, and 12-month postprocedure and until duration of clinical response. The primary outcome was the change from baseline in total IPSS, and secondary outcome were storage- and voiding-IPSS, QoL score, Qmax, and postvoiding residual volume (PVR), patient-reported outcomes. Adverse effects were also recorded, including ejaculatory dysfunctions. RESULTS: Of 30 enrolled patients (mean age 33.8 years), 29 (96.7%) completed the study. A statistically significant improvement of total IPSS was observed from 21.9 at baseline, to 7.8, 10.3, and 16.6 at 2, 6, and 9 months, respectively (P < 0.000). Statistically significant improvements from baseline of storage- and voiding-IPSS, QoL score, Qmax, and PVR were also observed until 9-month postprocedure. The proportion of patients with overall satisfaction was favorable although decreasing from 80% at 2 months, to 44.8% at 12 months. No significant adverse effects or ejaculatory dysfunctions were noted. CONCLUSIONS: BoNT-A injection therapy appears effective and safe in medically refractory men with PBND, although repeated procedures are required for long-term sustained benefit. Randomized controlled trials are warranted in order to corroborate these results.

Sexual outcomes after organ potency-sparing surgery and glans reconstruction in patients with penile carcinoma.

INTRODUCTION: Radical surgery is the "gold standard" for treatment of invasive penile carcinoma but very poor aesthetic, functional and psychological outcomes have been reported. Our purpose was to assess the impact of organ potency-sparing surgery in locally confined carcinoma of the penis. MATERIALS AND METHODS: We evaluated retrospectively 42 patients with early penile cancer (Ta,T1,T2), treated with glandulectomy and glanduloplasty with urethral mucosa and sparing of cavernosal apexes, or glandulectomy and limited apical resection in cases of Stage T2. Sexual function, ejaculation and libido were evaluated with an IIEF-15 questionnaire before the appearance of neoplasia (about three months before the surgery) and six months after surgery. Quality of life was evaluated by the Bigelow-Young questionnaire. The scores relating to two weeks prior to the surgery have been compared to those obtained six months after surgery. The statistical analysis was conducted using t-Student for repeated measures and analysis of variance. RESULTS: Six months after surgery 73% of patients reported spontaneous rigid erections, 60% coital activity while 76% of the group treated with urethral glanduloplasty reported normal ejaculation and orgasm, regained an average of 35 days after surgery. The average IIEF-15 scores reported in the entire series in the domains of erection, libido and coital activity of the pre-cancer period were not statistically different than those recorded six months after surgery. In the group treated with glandular reconstruction, pre-and postoperative IIEF-15 mean scores related to ejaculation and orgasm domains were not significantly different. Mean scores of Bigelow-Young questionnaires related to sexual pleasure, familial, social and professional relationships showed significant improvement after surgery. CONCLUSIONS: Potency sparing-sparing surgical treatments have a positive impact on a wide spectrum of the patient's life including family relationships, and social and working conditions.

(99m)Tc-MAG3 diuretic renography in diagnosis of obstructive nephropathy in adults: a comparison between F-15 and a new procedure F+10(sp) in seated position.

OBJECTIVE: The objective of this study was to compare 2 diuretic renography procedures: F-15 versus F+10(sp) for diagnosis of obstructive uropathy in adults. METHODS: Thirty-six patients with unilateral or bilateral hydronephrosis had 2 consecutive Tc-MAG3 diuretic renograms within 7 days, using the widely used procedure F-15 in supine position, and a new seated-position procedure whereby the patient drinks 400 to 500 mL of water at 5 minutes and receives an injection of 20 mg of furosemide at 10 minutes [F+10 (sp)]. RESULTS: F-15 showed nonobstructive results in 63.9% of kidneys, obstruction in 26.4%, and equivocal findings in 6.9% and was not applicable in 2.8%. F+10(sp) showed nonobstructive results in 70.9%, obstruction in 27.8%, and equivocal result in 1.4% of kidneys. Nephroptosis was observed by F+10(sp) in 22.2% of kidneys. Adverse effects reported for the F-15 were hypotension in 2 patients, renal colic in 3 patients, and interruption due to voiding in 5 patients. No adverse effects were reported for F+10(sp). CONCLUSIONS: This study shows that the F+10(sp) procedure reduces the equivocal findings of F-15 procedure in 36 patients. It can improve the accuracy and compliance, avoiding adverse effects and reducing bladder filling-related problems.

[An introduction to biomaterials in urology]. / I Biomateriali in Urologia. Un'introduzione.

Aim of this paper is to provide a brief introduction on the biomaterials used in urology, discussing issues of biocompatibility and biomaterials available for use. Information will moreover be provided on basic elements of Tissue engineering and Regenerative medicine, rapidly advancing technologies that could finally shift in the next future from the laboratory to clinical practice, with special interest to possible urological applications.

When to suspect a genetic disorder in a patient with renal stones, and why.

Nephrolithiasis is a common disorder, with a rising prevalence in the general population. Its pathogenesis is still unclear, but a role for genetics has long been recognized, especially in cases of the more common calcium nephrolithiasis. Although relatively rare, monogenic causes of hypercalciuria and nephrolithiasis do exist and their timely recognition is important from a prognostic and therapeutic viewpoint. This article reviews the clinical and laboratory findings characterizing inherited causes of nephrolithiasis with a view to helping clinicians to recognize and manage these rare conditions.

Advanced bladder cancer: new agents and new approaches. A review.

OBJECTIVE: The aim of the present paper is to review findings from the most relevant studies and evaluate the potential of new drugs in treatment of metastatic urothelial cancer. METHODS: Studies were identified by searching MEDLINE and Pubmed databases up to 2009 using both medical subject heading (Mesh) and a free text strategy with the name of known individual chemotherapeutic drug and the following key words: 'muscle-invasive bladder cancer', 'urothelial/transitional carcinoma', 'chemotherapeutics drugs and agents'. At the end of our research in literature we selected 63 articles and we have considered only studies in which almost 30 patients were enrolled. RESULTS: Radical cystectomy with pelvic lymph node dissection is the gold standard of treatment for clinically localized muscle-invasive bladder cancer. While more extensive lymph node dissection may have both prognostic and therapeutic significance, effective systemic therapies that eliminate micrometastases may improve outcome. Perioperative chemotherapy can be administered before (neoadjuvant) or after (adjuvant) cystectomy to eradicate subclinical disease and to improve survival. CONCLUSION: The challenge remains as to how to integrate all of the relevant knowledge and data in a systematic manner so that researchers can gain the knowledge needed to devise the best therapeutic and diagnostic strategies. Future improvements in the treatment of advanced bladder cancer will rely not only on the optimization of currently available cytotoxic agents but also on the biologic profile of individual patient tumors and the appropriate therapies that target molecular aberrations unique to this malignancy.

Urological complications following inguinal hernioplasty.

Aim of this paper is to report a systematic review of the literature about the incidence and putative mechanisms of genital tract injuries following open and laparoscopic herniorraphy and their effects on sexual function and fertility and to point out the measures of prevention and of treatment. The most frequently described events have been intraoperative complications as bladder or spermatic cord structure damage, immediate postoperative complications as ischaemic orchitis, urinary retention, urinary tract infection, hydrocele or scrotal haematoma and bacterial orchitis, or long-term complications as chronic orchialgia, testis atrophy, sexual dysfunction and infertility. The evidence of literature shows that urological complication after hernioplasty are under-reported. Only a small number of studies to date have essentially dealt with sexual quality of life after inguinal hernia surgical repair. The sexual needs of patients with groin hernias are rarely discussed. Extensive laparoscopic procedures, due to the need of learning curve, have increased the risk of vas damage and infertility in young patients candidate to hernioplasty. Early diagnosis prevents urological complication as well as possible legal claims after hernia repair: it should be include careful history, objective and subjective symptoms and signs of uro-genital pathologies, lab data when necessary, immediate eco-color-Doppler imaging and urgent urological consultation. Despite the lack of prospective randomized trials, there is a growing evidence in literature about positive impact of hernioplasty on sexual function, encouraging future studies on this issue.

Hot topics in urological health economics. A mini review.

Urological diseases are becoming a major public health problem. In fact, they increasingly weigh on the economy of a country due to the high direct costs and the consequent significant loss of productivity. Prostate cancer represents 11% of the costs for the treatment of all cancers in the United States with $8 billion and a cost per-patient from diagnosis to death of $81,658. Instead bladder cancer has the higher costs per-patient in terms of medical care, from diagnosis until death (U.S. $ 96,553). In Italy, in a reference hospital, the average costs of non muscle-invasive forms treated with endoscopic resection (TURB) and infiltrating forms treated with radical cystectomy are approximately Euro 2242.20 and Euro 6860 respectively, but they increase due to the follow-up and the ancillary treatments. In the field of functional disease, in the U.S. the average annual expenditure per capita for incontinence, including inpatient and outpatient services is $1382. While for patients who had undergone surgery the average total spending rose to $3620. For overactive bladder the total cost in the United States is estimated at 12.02 billion U.S. dollars, with $9.17 billion allocated to the community costs and $ 2.85 billion for institutional costs. However, further pharmacoeconomic studies are required to better understand the net economic impact of any alternative strategies to those actually present. Stone disease is a highly prevalent and costly condition for which United States total health care expenditures, in the year 2000, were estimated to be almost $ 2.1 billion. Treatment of nephrolithiasis depends on stone size and location, but typically involves a surgical procedure such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic laser lithotripsy, percutaneous nephrostolithotomy (PCNL) or open stone surgery with an average expenditure per procedure of $2295, $1425, $3624, $2916 respectively.

Microbiological follow-up of nosocomial infections in a single urological center.

BACKGROUND: To analyze data from the cultural examinations of different biological fluids, obtained from urologic patients from January 2007 to April 2010, in order to describe the incidence of infections in our setting. METHODS: In the period of reference a urine culture was carried out for every patient admitted, in case of suspected urinary tract infection, a blood culture in case of suspected sepsis, and a wound culture in case of wound infection. RESULTS: In the period of investigation 321 patients developed some kind of infection: 589 positive isolations obtained from cultural examinations have been diagnosed in urine (63%), blood (6%), surgical wound (6%), venous central catheter (7%) and other sites (18%) (tip of ureteral and bladder catheters). The most commonly isolated pathogenic agent for all the sites of infection has been Escherichia coli (22.5%). In urine, the most frequently isolated species have been Escherichia coli (27.8%), Enterococcus (12.5%), and Candida spp (9.3%). Escherichia coli (22.9%), Pseudomonas (5.7%), and Staphylococcus aureus (3.5%) were the most frequently found pathogenic agents responsible for sepsis, compared to others. In the period of investigation we have recorded 35 episodes of sepsis. CONCLUSIONS: Empiric antibiotic therapy is frequent in cases of clinical evidence of infection, before the identification of the causative microorganism is available; therefore, it is important to know which are the bacterial species mainly responsible for these specific infections. We need continuous surveillance of infections and the improvement in the use of antibiotic therapy in order to limit the antimicrobial resistance.