Andreas Skolarikos

EAU Guidelines on Interventional Treatment for Urolithiasis

CONTEXT Management of urinary stones is a major issue for most urologists. Treatment modalities are minimally invasive and include extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PNL). Technological advances and changing treatment patterns have had an impact on current treatment recommendations, which have clearly shifted towards endourologic procedures. These guidelines describe recent recommendations on treatment indications and the choice of modality for ureteral and renal calculi. OBJECTIVE To evaluate the optimal measures for treatment of urinary stone disease. EVIDENCE ACQUISITION Several databases were searched to identify studies on interventional treatment of urolithiasis, with special attention to the level of evidence. EVIDENCE SYNTHESIS Treatment decisions are made individually according to stone size, location, and (if known) composition, as well as patient preference and local expertise. Treatment recommendations have shifted to endourologic procedures such as URS and PNL, and SWL has lost its place as the first-line modality for many indications despite its proven efficacy. Open and laparoscopic techniques are restricted to limited indications. Best clinical practice standards have been established for all treatments, making all options minimally invasive with low complication rates. CONCLUSION Active treatment of urolithiasis is currently a minimally invasive intervention, with preference for endourologic techniques. PATIENT SUMMARY For active removal of stones from the kidney or ureter, technological advances have made it possible to use less invasive surgical techniques. These interventions are safe and are generally associated with shorter recovery times and less discomfort for the patient.

EAU Guidelines on Diagnosis and Conservative Management of Urolithiasis

CONTEXT Low-dose computed tomography (CT) has become the first choice for detection of ureteral calculi. Conservative observational management of renal stones is possible, although the availability of minimally invasive treatment often leads to active treatment. Acute renal colic due to ureteral stone obstruction is an emergency that requires immediate pain management. Medical expulsive therapy (MET) for ureteral stones can support spontaneous passage in the absence of complicating factors. These guidelines summarise current recommendations for imaging, pain management, conservative treatment, and MET for renal and ureteral stones. Oral chemolysis is an option for uric acid stones. OBJECTIVE To evaluate the optimal measures for diagnosis and conservative and medical treatment of urolithiasis. EVIDENCE ACQUISITION Several databases were searched for studies on imaging, pain management, observation, and MET for urolithiasis, with particular attention to the level of evidence. EVIDENCE SYNTHESIS Most patients with urolithiasis present with typical colic symptoms, but stones in the renal calices remain asymptomatic. Routine evaluation includes ultrasound imaging as the first-line modality. In acute disease, low-dose CT is the method of choice. Ureteral stones <6mm can pass spontaneously in well-controlled patients. Sufficient pain management is mandatory in acute renal colic. MET, usually with α-receptor antagonists, facilitates stone passage and reduces the need for analgesia. Contrast imaging is advised for accurate determination of the renal anatomy. Asymptomatic calyceal stones may be observed via active surveillance. CONCLUSIONS Diagnosis, observational management, and medical treatment of urinary calculi are routine measures. Diagnosis is rapid using low-dose CT. However, radiation exposure is a limitation. Active treatment might not be necessary, especially for stones in the lower pole. MET is recommended to support spontaneous stone expulsion. PATIENT SUMMARY For stones in the lower pole of the kidney, treatment may be postponed if there are no complaints. Pharmacological treatment may promote spontaneous stone passage.

Operating Times and Bleeding Complications in Percutaneous Nephrolithotomy: A Comparison of Tract Dilation Methods in 5537 Patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study

PURPOSE The study investigated factors that affect operating times and bleeding complications associated with percutaneous nephrolithotomy (PCNL) in the PCNL Global Study. PATIENTS AND METHODS All patients who underwent PCNL for primary or secondary treatment of kidney stone indications during the study period (November 2007-December 2009) were eligible for inclusion. PCNL procedures were performed according to local clinical guidelines and practices. Nephrostomy tract dilation was performed using balloon dilation, metal telescopic dilation, or Amplatz serial dilation. Hematologic complications assessed included bleeding rates, transfusion rates, and preoperative and postoperative hematocrit values. RESULTS The median operating time with balloon dilation (n=2277) was significantly longer than with telescopic/serial dilation (n=3260) at 94.0 vs 60.0 minutes, respectively (P<0.0001). In the balloon dilation group, there was significantly more bleeding (9.4% vs 6.7%, respectively; P<0.0001) and more transfusions (7.0% vs 4.9%, respectively; P=0.001) compared with the telescopic/serial dilator group. Univariate analysis showed that the probability of bleeding complications was higher with balloon vs telescopic/serial dilation (odds ratio [OR] 1.75; P=0.0001) and larger sheath size (OR 1.42; P=0.0001). By multivariate analysis, sheath size but not dilation method was predictive of bleeding complications. Other significant predictive factors included operating time, stone load, and caseload. CONCLUSION This study shows that in PCNL, factors that are associated with bleeding/transfusion include sheath size, operating time, stone load, and caseload.

Prevention and treatment of complications following percutaneous nephrolithotomy.

Purpose of review The aim of this article is to identify classification and grading systems of percutaneous nephrolithotomy-related complications and evidence for the prevention and treatment of these complications. Recent findings A total complication rate of up to 83% following percutaneous nephrolithotomy was recognized. These complications were mostly clinically insignificant including minor bleeding or fever. The frequency of major complications was 0.9–4.7% for septicemia, 0.6–1.4% for renal hemorrhage requiring intervention, 2.3–3.1% for pleural injury and 0.2–0.8% for colonic injury. The significance of grading perioperative complications according to their severity, emphasizing the need for a unique and broadly accepted classification system, which could be helpful for monitoring and reporting outcomes emerged from the current review. The modified Clavien system has recently been used for this purpose. Proper patient selection, preoperative imaging for planning the operation, adequate antibiotic prophylaxis and therapy, manipulation of the collecting system only under fluoroscopic or endoscopic control, use of a continuous flow system, use of normal saline as irrigant fluid, judicious stone fragmentation and finally fluoroscopic monitoring of nephrostomy tube insertion and removal are necessary to prevent percutaneous nephrolithotomy complications. Appropriate treatment has been sufficiently described in the literature. Summary Currently, a high index of suspicion and prompt recognition and institution of appropriate treatment of percutaneous nephrolithotomy-related complications is fundamental to limit morbidity.

Laser Treatment of Benign Prostatic Obstruction: Basics and Physical Differences

CONTEXT Laser treatment of benign prostatic obstruction (BPO) has become more prevalent in recent years. Although multiple surgical approaches exist, there is confusion about laser-tissue interaction, especially in terms of physical aspects and with respect to the optimal treatment modality. OBJECTIVE To compare available laser systems with respect to physical fundamentals and to discuss the similarities and differences among introduced laser devices. EVIDENCE ACQUISITION The paper is based on the second expert meeting on the laser treatment of BPO organised by the European Association of Urology Section of Uro-Technology. A systematic literature search was also carried out to cover the topic of laser treatment of BPO extensively. EVIDENCE SYNTHESIS The principles of generation of laser radiation, laser fibre construction, the types of energy emission, and laser-tissue interaction are discussed in detail for the laser systems used in the treatment of BPO. The most relevant laser systems are compared and their physical properties discussed in depth. CONCLUSIONS Laser treatment of BPO is gaining widespread acceptance. Detailed knowledge of the physical principles allows the surgeon to discriminate between available laser systems and their possible pitfalls to guarantee high safety levels for the patient.

Short- and long-term complications of open radical prostatectomy according to the Clavien classification system.

To assess the use of the Clavien classification system in documenting the complications related to open retropubic radical prostatectomy (RRP).

Metabolic evaluation and recurrence prevention for urinary stone patients: EAU guidelines.

CONTEXT An optimum metabolic evaluation strategy for urinary stone patients has not been clearly defined. OBJECTIVE To evaluate the optimum strategy for metabolic stone evaluation and management to prevent recurrent urinary stones. EVIDENCE ACQUISITION Several databases were searched to identify studies on the metabolic evaluation and prevention of stone recurrence in urolithiasis patients. Special interest was given to the level of evidence in the existing literature. EVIDENCE SYNTHESIS Reliable stone analysis and basic metabolic evaluation are highly recommended in all patients after stone passage (grade A). Every patient should be assigned to a low- or high-risk group for stone formation. It is highly recommended that low-risk stone formers follow general fluid and nutritional intake guidelines, as well as lifestyle-related preventative measures to reduce stone recurrences (grade A). High-risk stone formers should undergo specific metabolic evaluation with 24-h urine collection (grade A). More specifically, there is strong evidence to recommend pharmacological treatment of calcium oxalate stones in patients with specific abnormalities in urine composition (grades A and B). Treatment of calcium phosphate stones using thiazides is only highly recommended when hypercalciuria is present (grade A). In the presence of renal tubular acidosis (RTA), potassium citrate and/or thiazide are highly recommended based on the relative urinary risk factor (grade A or B). Recommendations for therapeutic measures for the remaining stone types are based on low evidence (grade C or B following panel consensus). Diagnostic and therapeutic algorithms are presented for all stone types based on the best level of existing evidence. CONCLUSION Metabolic stone evaluation is highly recommended to prevent stone recurrences. PATIENT SUMMARY In this report, we looked at how patients with urolithiasis should be evaluated and treated in order to prevent new stone formation. Stone type determination and specific blood and urine analysis are needed to guide patient treatment.

Incontinence and erectile dysfunction following radical prostatectomy: a review.

Radical prostatectomy remains the treatment of choice for localized prostate cancer in age-appropriate and health-appropriate men. Although cancer control is the most important aspect of a radical prostatectomy, minimization of postoperative morbidity, especially urinary incontinence and erectile dysfunction, is becoming a greater concern. We reviewed recent data available on Medline regarding the incidence, pathophysiology, evaluation, and treatment of incontinence and sexual dysfunction after radical prostatectomy. Health-related quality of life issues have been specifically addressed. Although low incidences of incontinence and erectile dysfunction after radical prostatectomy have been reported in the hands of experienced surgeons, the literature review revealed a great variety, with incontinence rates ranging from 0.3–65.6% and potency rates ranging from 11–87%. Several factors contribute to this wide difference, the most important being the application of a meticulous surgical technique. General and cancer-specific health-related quality of life is not being affected after radical prostatectomy. The incidence of incontinence and erectile dysfunction is higher after radical prostatectomy when compared to the incidence observed when other therapies for localized prostate cancer are applied. However, the majority of the patients undergoing radical prostatectomy would vote for the operation again. Today, avoidance of major complications after radical prostatectomy depends mostly on a high-quality surgical technique. When incontinence or erectile dysfunction persists after radical prostatectomy, the majority of the treated patients can be managed effectively by various methods.

Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate: COMPARISON OF B-TURP VS M-TURP IN A MULTICENTRE RCT SETTING

Study Type – Therapy (RCT)

Is there still a role for open surgery in the management of renal stones

Purpose of review In the last few decades, with the improvement in endourological surgery and the invention and evolution of extracorporeal shock-wave lithotripsy, the indications for open surgery in stone disease have become rare, although open surgery still has a role in selected cases. In this review we discuss the current indications of open surgery for the elimination of urinary calculi. Recent findings A MEDLINE and MeSH search was performed to evaluate currently available guidelines on open stone surgery and identify the evidence-based medicine that support the role of open surgery in treating urinary lithiasis. The latest papers published on open stone surgery are reviewed and conclusions are drawn, based on their results. Summary Open stone surgery should be avoided in most cases, but should be considered for those patients in whom a reasonable number of less invasive procedures would not be useful. The most common indications for open stone surgery include complex stone burden, failure of extracorporeal shock-wave lithotripsy or endourological treatment and anatomical abnormalities (such as ureteropelvic junction obstruction and infundibular stenosis with or without renal caliceal diverticulum). The level of evidence for the currently available guidelines is not adequate, mainly because of lack of properly designed, large prospective randomized trials that compare different treatment options.