Ureteroscopy from the recent past to the near future.

Stone surgery is one of oldest surgical practices undertaken by man. Hippocrates refused to let his followers "cut for the stone" and it was only in February 1980, when the first human trial of shock wave therapy on a renal stone was performed with success that a new era in minimally invasive treatment (surgery) for stones was opened up and this condemnation was finally resolved in the Hippocratic Oath. Endoscopy, using natural orifices, supported by anaesthesia, incremented by technology and with access to all points along the urinary tract, began by competing with ESWL, but is now the treatment of choice in most cases. As far as we know humans have always had stones. First, lithiasis was endemic bladder stones in children, now it is renal in general. Added to this a number of well-known risk factors, a rapid increase in obesity in the population, as well as bariatric surgery for its treatment, are causing an increase in the prevalence and recurrence of lithiasis everywhere. A short history of the advances made with the introduction and development of the ureteroscope, along with auxiliary devices, will show why this is the preferred technique at the moment for treating lithiasis in general and for treating stones in pregnant women, children and the obese in particular. Being a minimally invasive surgery, with a low morbidity and a very high efficiency and stonefree rate, has become established as a clear future technique for both adults and children. This development is not only due to technological advancements, but also to the routine use of the Holmium: YAG LASER for intracorporeal lithotripsy, capable of destroying any stone regardless of its composition or location, surpassing the ability of any other lithotripter. It is also due to the development of devices that allow access to the ureter and all parts of the kidney, as well as auxiliary aids to assist in the handling of stones during treatment. New LASERs, robotic control of the fdURS and digital imaging, as well as disposable devices, have had and, indeed, continue to have a unique impact on future development in this field. However, success will continue to depend on the careful choice of fURS, energy source and ancillary instruments obtained by the urologist during both real life and virtual training in human simulators.

Metabolic diagnosis and medical prevention of calcium nephrolithiasis and its systemic manifestations: a consensus statement.

BACKGROUND: Recently published guidelines on the medical management of renal stone disease did not address relevant topics in the field of idiopathic calcium nephrolithiasis, which are important also for clinical research. DESIGN: A steering committee identified 27 questions, which were proposed to a faculty of 44 experts in nephrolithiasis and allied fields. A systematic review of the literature was conducted and 5216 potentially relevant articles were selected; from these, 407 articles were deemed to provide useful scientific information. The Faculty, divided into working groups, analysed the relevant literature. Preliminary statements developed by each group were exhaustively discussed in plenary sessions and approved. RESULTS: Statements were developed to inform clinicians on the identification of secondary forms of calcium nephrolithiasis and systemic complications; on the definition of idiopathic calcium nephrolithiasis; on the use of urinary tests of crystallization and of surgical observations during stone treatment in the management of these patients; on the identification of patients warranting preventive measures; on the role of fluid and nutritional measures and of drugs to prevent recurrent episodes of stones; and finally, on the cooperation between the urologist and nephrologist in the renal stone patients. CONCLUSIONS: This document has addressed idiopathic calcium nephrolithiasis from the perspective of a disease that can associate with systemic disorders, emphasizing the interplay needed between urologists and nephrologists. It is complementary to the American Urological Association and European Association of Urology guidelines. Future areas for research are identified.

Quality Assessment of Urinary Stone Analysis: Results of a Multicenter Study of Laboratories in Europe.

After stone removal, accurate analysis of urinary stone composition is the most crucial laboratory diagnostic procedure for the treatment and recurrence prevention in the stone-forming patient. The most common techniques for routine analysis of stones are infrared spectroscopy, X-ray diffraction and chemical analysis. The aim of the present study was to assess the quality of urinary stone analysis of laboratories in Europe. Nine laboratories from eight European countries participated in six quality control surveys for urinary calculi analyses of the Reference Institute for Bioanalytics, Bonn, Germany, between 2010 and 2014. Each participant received the same blinded test samples for stone analysis. A total of 24 samples, comprising pure substances and mixtures of two or three components, were analysed. The evaluation of the quality of the laboratory in the present study was based on the attainment of 75% of the maximum total points, i.e. 99 points. The methods of stone analysis used were infrared spectroscopy (n = 7), chemical analysis (n = 1) and X-ray diffraction (n = 1). In the present study only 56% of the laboratories, four using infrared spectroscopy and one using X-ray diffraction, fulfilled the quality requirements. According to the current standard, chemical analysis is considered to be insufficient for stone analysis, whereas infrared spectroscopy or X-ray diffraction is mandatory. However, the poor results of infrared spectroscopy highlight the importance of equipment, reference spectra and qualification of the staff for an accurate analysis of stone composition. Regular quality control is essential in carrying out routine stone analysis.

Nephrolithiasis: why doesn't our "learning" progress?

OBJECTIVE: Stone research is stagnant with minor clinical fall-out. We wonder whether this, in the ESWL era, depends only on ESWL and the consequent change in our clinical management habits, or is rather due to mistakes made by investigators. We feel that indeed we did and do make some: (1) the patients we are investigating may not be appropriate; and (2) we are missing to properly recognise disease heterogeneity. CONCLUSIONS: From the public health side most likely we are not investigating the right patients, and we probably need to address the large part of the problem, i.e. the rarely relapsing stone formers demanding 80% of all urological interventions. Although there is a consensus that urolithiasis is very heterogeneous, this position is presently under reconsideration. It is necessary to investigate the single or "occasional" stone former, and go back to the epidemiology and clinics with multicentre, prospective studies. Being a multifactorial disease, we will need to evaluate as many aspects as possible contemporaneously in the same patient. It is also necessary to "revisit" the disease in an unbiased manner, because its relationship with relevant aspects could be different than previously thought due to our incomplete knowledge of its pathogenesis and pathophysiology.