Dean G. Assimos

URETERAL STONES CLINICAL GUIDELINES PANEL SUMMARY REPORT ON THE MANAGEMENT OF URETERAL CALCULI

Purpose The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data.PURPOSE The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data. MATERIALS AND METHODS The panel searched the MEDLINE data base for all articles related to ureteral calculi published from 1966 to January 1996. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative treatments of ureteral calculi. RESULTS The data indicate that up to 98% of stones less than 0.5 cm. in diameter, especially in the distal ureter, will pass spontaneously. Shock wave lithotripsy is recommended as first line treatment for most patients with stones 1 cm. or less in the proximal ureter. Shock wave lithotripsy and ureteroscopy are acceptable treatment choices for stones 1 cm. or less in the distal ureter. CONCLUSIONS Most ureteral stones will pass spontaneously. Those that do not can be removed by either shock wave lithotripsy or ureteroscopy. Traditional blind basket extraction, without fluoroscopic control and guide wires, is not recommended. Open surgery is appropriate as a salvage procedure or in certain unusual circumstances.

The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: Indications, Complications, and Outcomes in 5803 Patients

PURPOSE To assess the current indications, perioperative morbidity, and stone-free outcomes for percutaneous nephrolithotomy (PCNL) worldwide. PATIENTS AND METHODS The Clinical Research Office of the Endourological Society (CROES) collected prospective data for consecutive patients who were treated with PCNL at centers around the world for 1 year. PCNL was performed according to study protocol and local clinical practice guidelines. Stone load and location were recorded, and postoperative complications were graded according to the modified Clavien grading system. RESULTS Between November 2007 and December 2009, 5803 patients were treated at 96 centers in Europe, Asia, North America, South America, and Australia. Staghorn calculus was present in 1466 (27.5%) patients, and 940, 956, and 2603 patients had stones in the upper, interpolar, and lower pole calices, respectively. The majority of procedures (85.5%) were uneventful. Major procedure-related complications included significant bleeding (7.8%), renal pelvis perforation (3.4%), and hydrothorax (1.8%). Blood transfusion was administered in 328 (5.7%) patients, and fever >38.5°C occurred in 10.5% of patients. The distribution of scores in modified Clavien grades was: No complication (79.5%), I (11.1%), II (5.3%), IIIa (2.3%), IIIb (1.3%), IVa (0.3%), IVb (0.2%), or V (0.03%). At follow-up. the 30-day stone-free rate was 75.7%, and 84.5% of patients did not need additional treatment. CONCLUSION With a high success rate and a low major complication rate, PCNL is an effective and safe technique overall for minimally invasive removal of kidney stones.

LOWER POLE I: A PROSPECTIVE RANDOMIZED TRIAL OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL RESULTS

PURPOSE The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

2007 Guideline for the management of ureteral calculi.

TheAmericanUrologicalAssociationNephrolithiasis Clinical Guideline Panel was established in 1991. Since that time, the Panel has developed three guidelines on the management of nephrolithiasis, the most recent being a 2005 update of the original 1994 Report on the Management of Staghorn Calculi [1]. The European Association of Urology began their nephrolithiasis guideline project in 2000, yielding the publication of Guidelines on Urolithiasis, with updates in 2001 and 2006 [2]. While both documents provide useful recommendations on the management of ureteral calculi, changes in shock-wave lithotripsy technology, endoscope design, intracorporeal lithotripsy techniques, and laparoscopic expertise have burgeoned over the past five to ten years. Under the sage leadership of the late Dr. JosephW. Segura, the AUA Practice Guidelines Committee suggested to both the AUA and the EAU that they join efforts in developing the first set of internationally endorsed guidelines focusing on the changes introduced in ureteral stone management over the last decade. We therefore dedicate this report to the memory of Dr. Joseph W. Segura whose vision, integrity, and perseverance led to the establishment of the first international guideline project. This joint EAU/AUA Nephrolithiasis Guideline Panel (hereinafter the Panel) performed a systematic review of the English language literature published since 1997 and a comprehensively analyzed outcomes data from the identified studies. Based on their findings, the Panel concluded that when removal becomes necessary, SWL and ureteroscopy remain the two primary treatment modalities for the management of symptomatic ureteral calculi. Other treatments were reviewed, including medical expulsive therapy to facilitate spontaneous stone passage, percutaneous antegrade ureteroscopy, and laparoscopic and open surgical ureterolithotomy. In concurrence with the previously published guidelines of both organizations, open stone surgery is still considered a secondary treatment option. Blind basketing of ureteral calculi is not recommended. In addition, the Panel was able to provide some guidance e u r o p e a n u r o l og y 5 2 ( 2 0 0 7 ) 1 6 1 0 – 1 6 3 1

Nephrolithiasis Clinical Guidelines Panel Summary Report on the Management of Staghorn Calculi

The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommendations for managing struvite staghorn calculi are based on a comprehensive review of the treatment literature and meta-analysis of outcome data from the 110 pertinent articles containing viable, unduplicated data. The panel concluded that the 3 most significant outcome probabilities are those of being stone-free, undergoing secondary unplanned procedures and having associated complications. Panel guideline recommendations for most standard patients are that neither shock wave lithotripsy monotherapy nor open surgery should be a first-line treatment choice but that a combination of percutaneous stone removal and shock wave lithotripsy should be used.

Changing incidence and etiology of iatrogenic ureteral injuries.

In the last decade there have been major advances in endoscopic surgery including ureteroscopy and laparoscopy, both of which may cause ureteral injury. We sought to determine if increased use of these procedures affected the frequency and nature of major iatrogenic ureteral injuries managed at our medical center. From 1980 to 1984 we treated 8 patients with such injuries compared to 19 patients treated from 1985 to 1989. The most recent period corresponded to the institution of ureteroscopy and the use of more aggressive laparoscopic procedures. Of the patients 14 sustained injuries at our center while 13 were referred from other institutions. Between 1985 and 1989 the incidence of injuries per total hospital admissions at risk increased from 4 to 11 per 10,000 (p = 0.0067), the incidence of urological injuries increased from 4 to 23 per 10,000 (p = 0.0071) and the incidence of injuries occurring in gynecologic patients increased from 13 to 41 per 10,000 admissions (p = 0.0385). There was no difference in the incidence of injuries in the general surgical population. From 1980 to 1984 no laparoscopic or ureteroscopic injuries occurred. However, from 1985 to 1989, 25% of gynecologic injuries occurred during laparoscopy and 70% of urological injuries were sustained during ureteroscopic procedures. Depending on the extent of the injury, patients were initially treated with either endourological or open surgical procedures. Good results were obtained in the majority of cases. Contemporary therapeutic strategies for treating patients sustaining ureteral injuries are discussed.

Clinical Effectiveness Protocols for Imaging in the Management of Ureteral Calculous Disease: AUA Technology Assessment

PURPOSE This technology assessment addresses the optimal use of imaging in the evaluation and treatment of patients with suspected or documented ureteral stones. MATERIALS AND METHODS A comprehensive literature search addressing 4 guiding questions was performed for full text in English articles published between January 1990 and July 2011. The search focused on major subtopics associated with the imaging of ureteral calculi, and included specific imaging modalities used in the diagnosis and management of ureteral calculous disease such as unenhanced (noncontrast) computerized tomography, conventional radiography, ultrasound, excretory urography, magnetic resonance imaging and nuclear medicine studies. Protocols (in the form of decision tree algorithms) were developed based on this literature review and in some instances on panel opinion. The 4 questions addressed were 1) What imaging study should be performed for suspected ureteral calculous disease? 2) What information should be obtained? 3) After diagnosis of a ureteral calculus, what followup imaging should be used? 4) After treatment of a ureteral calculus, what followup imaging studies should be obtained? RESULTS Based on these protocols, noncontrast computerized tomography is recommended to establish the diagnosis in most cases, with a low energy protocol advocated if body habitus is favorable. Conventional radiography and ultrasound are endorsed for monitoring the passage of most radiopaque stones as well as for most patients undergoing stone removal. Other studies may be indicated based on imaging findings, and patient, stone and clinical factors. CONCLUSIONS The protocols generated assist the clinician in establishing the diagnosis of ureteral calculous disease, monitoring stone passage and following patients after treatment. The protocols take into account not only clinical effectiveness but also cost-effectiveness and risk/harm associated with the various imaging modalities.

GLYOXYLATE SYNTHESIS, AND ITS MODULATION AND INFLUENCE ON OXALATE SYNTHESIS

PURPOSE We define the major pathways of hepatic oxalate synthesis in humans, examine the association with other metabolic pathways and identify ways that oxalate synthesis may be modified. In addition, we suggest what is required for further progress in this area. MATERIALS AND METHODS We consolidated relevant data primarily from recently published literature, considered new pharmacological approaches to decrease oxalate synthesis, and formulated an overview of the regulation and modification of oxalate synthesis pathways. RESULTS Experiments with animals, including humans, animal cells and in vitro preparations of cellular components, support the existence of a major metabolic pathway linking the amino acids serine, glycine and alanine. Oxalate synthesis is a minor, secondary reaction of a cascade of reactions termed the glyoxylate pathway, which has a prominent role in gluconeogenesis and ureagenesis. The enzymatic steps and effectors which regulate glyoxylate and oxalate synthesis are not well characterized. Pharmacological approaches can reduce oxalate synthesis by diminishing the glyoxylate pool and possibly modifying enzymatic reactions leading to glyoxylate synthesis. CONCLUSIONS The individual steps associated with glyoxylate and oxalate synthesis can be identified. The glyoxylate pathway has a significant functional role in intermediary liver metabolism but the way it is regulated is uncertain. Oxalate synthesis can be modified by drugs, indicating that primary and idiopathic hyperoxaluria may respond to pharmacological intervention.

Quantitative Assessment of Citric Acid in Lemon Juice, Lime Juice, and Commercially-Available Fruit Juice Products

BACKGROUND AND PURPOSE Knowledge of the citric acid content of beverages may be useful in nutrition therapy for calcium urolithiasis, especially among patients with hypocitraturia. Citrate is a naturally-occurring inhibitor of urinary crystallization; achieving therapeutic urinary citrate concentration is one clinical target in the medical management of calcium urolithiasis. When provided as fluids, beverages containing citric acid add to the total volume of urine, reducing its saturation of calcium and other crystals, and may enhance urinary citrate excretion. Information on the citric acid content of fruit juices and commercially-available formulations is not widely known. We evaluated the citric acid concentration of various fruit juices. MATERIALS AND METHODS The citric acid content of 21 commercially-available juices and juice concentrates and the juice of three types of fruits was analyzed using ion chromatography. RESULTS Lemon juice and lime juice are rich sources of citric acid, containing 1.44 and 1.38 g/oz, respectively. Lemon and lime juice concentrates contain 1.10 and 1.06 g/oz, respectively. The citric acid content of commercially available lemonade and other juice products varies widely, ranging from 0.03 to 0.22 g/oz. CONCLUSIONS Lemon and lime juice, both from the fresh fruit and from juice concentrates, provide more citric acid per liter than ready-to-consume grapefruit juice, ready-to-consume orange juice, and orange juice squeezed from the fruit. Ready-to-consume lemonade formulations and those requiring mixing with water contain < or =6 times the citric acid, on an ounce-for-ounce basis, of lemon and lime juice.

Changing indications of open stone surgery

OBJECTIVES To compare the current role of open stone surgery at our institution to previously reported data. In 1989, the indications for open surgical treatment of urinary calculi at our institution were reviewed. In the intervening years, tremendous advances have been made in minimally invasive treatment of urinary calculi. METHODS A retrospective evaluation of all patients undergoing procedures for the purpose of stone removal or fragmentation at Wake Forest University Baptist Medical Center between January 1, 1998 and May 31, 2001 was conducted. This was compared with data reported from our institution describing similar procedures in the first 19 months after introduction of the Dornier HM3 lithotriptor. RESULTS Of 986 procedures performed for the purpose of stone removal or fragmentation between January 1, 1998 and May 31, 2001, 0.7% were open surgical procedures. Of these procedures, 85.8% were performed for anatomic indications. Patients referred from other institutions for evaluation after endoscopic treatment failure comprised the remaining 14.2% of this group. In the previously reported data, 893 procedures were performed for the treatment of urinary calculi, of which 4.1% were open operations. Of these patients, 48.6% underwent an open surgical procedure after unsuccessful endoscopic treatment of urinary calculi, and 48.7% of these patients underwent open surgery for anatomic indications. CONCLUSIONS Open surgical stone removal remains a viable treatment option for select patients. Technologic advances and improved surgical skills have greatly reduced the number of patients requiring open surgery. This approach is mainly used for patients with complex calculous disease associated with anatomic abnormalities.