BACKGROUND AND OBJECTIVE: Stone size has traditionally been measured in one dimension. This is reflected in most of the literature and in the EAU guidelines. However, recent studies have shown that multidimensional measures provide better prediction of outcomes. METHODS: We performed a systematic review and meta-analysis of the prognostic accuracy of measures of stone size (PROSPERO reference CRD42022346967). We considered all studies reporting prognostic accuracy statistics on any intervention for kidney stones (extracorporeal shockwave lithotripsy [ESWL], ureterorenoscopy [URS], or percutaneous nephrolithotomy [PCNL]; Population) using multiplane measurements of stone burden (area in mm2 or volume in mm3; Intervention) in comparison to single-plane measurements of stone burden (size in mm; Intervention) for the study-defined stone-free rate (Outcome) in a PICO-framed question. We also assessed complication rates (overall and by Clavien-Dindo grade) and the operative time as secondary outcomes. Searches were made between 1970 and August 2023. We used the DeLong method to compare receiver operating characteristic (ROC) curves. KEY FINDINGS AND LIMITATIONS: Of 24 studies included in the review, 12 were eligible for comparative analysis with the DeLong test following meta-analysis of prognostic accuracy. For prediction of stone-free status, the area under the ROC curve (AUC) was significantly higher for stone volume than for stone size (0.71 vs 0.67; p < 0.001). Subanalyses confirmed this for ESWL and URS, but not for PCNL. For URS, the AUC was also significantly higher for stone area than for stone size (0.79 vs 0.77; p < 0.001). Throughout all analyses, there was no difference in AUC between stone area and stone volume. There was high risk of bias for all analyses apart from the URS subanalyses. CONCLUSIONS AND CLINICAL IMPLICATIONS: According to the limited data currently available, stone-free rates are predicted with significantly higher accuracy using multidimensional measures of stone burden in comparison to a single linear measurement. PATIENT SUMMARY: We reviewed different ways of measuring the size of stones in the kidney or urinary tract and compared their accuracy in predicting stone-free rates after treatment. We found that measurement of the stone area (2 dimensions) or stone volume (3 dimensions) is better than stone diameter (1 dimension) in predicting stone-free status after treatment.
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Po dobu téměř celého století se jako zlatý standard operací pro benigní hyperplazii prostaty (BHP) etablovaly metody omezené velikostí prostaty. Pro žlázy nad 80 g otevřená prostatektomie (OP), pro menší transuretrální prostatektomie (TURP). Přes nesporný efekt přinášejí vysokou míru morbidity. Technologický rozvoj 90. let 20. století umožnil nové operační postupy, z nichž se jako metoda nezávislá na velikosti prostaty ustavuje enukleace prostaty holmiovým laserem (HoLEP). Snažíme se podat přehled o vývoji metody, alternativních postupech a nových technologických možnostech. Zároveň přinášíme porovnání v různých parametrech s doposud standardními postupy. Stále více literárních pramenů považuje Ho - LEP za efektní, bezpečnou a dlouhodobě účinnou metodu operační léčby BHP. Na základě toho v doporučených postupech postupně nahrazuje TURP a OP jako nová metoda volby. HoLEP je nadále nutno zvažovat jako možnost číslo jedna při plánování operací na prostatě, bez ohledu na její velikost. Lze jej nabídnout i pacientům s vyšším rizikem krvácení, po biopsii i po předchozích výkonech na prostatě. Rozvoj technologií slibuje další zrychlení a zvýšení bezpečnosti výkonu, který se stává novým zlatým standardem.
For nearly a century, methods limited by the size of the prostate have been established as the gold standard of surgery for benign prostatic hyperplasia (BPH). For glands over 80g open prostatectomy (OP) and for smaller ones transurethral prostatectomy (TURP). Despite their indisputable effect, they bring a high rate of morbidity. The technological development of the 90s of the 20th century enabled new surgical procedures of which Holmium laser enucleation of the prostate (HoLEP) is established as a size-independent method. We try to provide an overview of the development of the method, alternative procedures and new technological possibilities. At the same time we bring a comparison of various parameters with standard procedures up to now. More and more literary sources consider HoLEP to be an effective, safe and long-term effective method of surgical treatment of BPH. Based on this, it is gradually replacing TURP and OP as the new method of choice in the guidelines. HoLEP should be considered as the number one option when planning prostate surgery regardless of prostate size. It can also be offered to patients with a higher risk of bleeding, after a biopsy or after previous procedures on the prostate. The development of technologies promises further speed-up and better safety profile of the procedure which is becoming the new gold standard in BHP surgery.
- Klíčová slova
- holmiový laser,
- MeSH
- hyperplazie prostaty * chirurgie MeSH
- laserová terapie * přístrojové vybavení MeSH
- lidé MeSH
- prostatektomie metody MeSH
- symptomy dolních močových cest patologie MeSH
- transuretrální resekce prostaty MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- přehledy MeSH
Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.
- MeSH
- kvalita života MeSH
- ledviny MeSH
- lidé MeSH
- litotripse * metody MeSH
- močové kameny * terapie MeSH
- urolitiáza * terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- směrnice pro lékařskou praxi MeSH
- MeSH
- dospělí MeSH
- lidé MeSH
- následné studie MeSH
- propuštění pacienta MeSH
- urologie * MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- dopisy MeSH
- komentáře MeSH
- metaanalýza MeSH
- systematický přehled MeSH
PURPOSE: We sought to determine which treatment between flexible ureteroscopy and shock wave lithotripsy has a better stone-free rate in pediatric patients (<18 years) with renal or proximal ureteric stones (<2 cm). Subanalysis for all outcomes for randomized controlled trials only. MATERIALS AND METHODS: Using PubMed, Web of Science, and the Cochrane database, we identified studies (randomized clinical trials and prospective comparative nonrandomized studies) published until August 2022 reporting surgical outcomes of pediatrics patients undergoing flexible ureteroscopy and shock wave lithotripsy with renal or proximal ureteric stones <2 cm (PROSPERO ID: CRD42022378790). Only randomized controlled trials were considered for meta-analysis. Stone-free rate, operative time, and complications were analyzed. Analysis was performed in R. RESULTS: A total of 6 studies identified, of which 3 were randomized clinical trials and 4 had data on renal stones. A total of 669 patients were analyzed. Mean age ranged from 4.4 to 12.4 years. The shock wave lithotripsy group presented a range of stone-free rate between 21 and 90% while the flexible ureteroscopy group presented a range of stone-free rates between 37% and 97%. Meta-analysis of randomized controlled trials only (n=302) demonstrated significantly higher stone-free rate in flexible ureteroscopy vs shock wave lithotripsy (RR = 1.17, 95% CI: 1.04-1.33, P = 0.01), operative time (mean difference = +16.4 minutes, 95% CI: 7.3-25.5, P < 0.01) and hospital stay (mean difference = +0.25 days, 95% CI: 0.14-0.36, P < 0.001). But no difference in fluoroscopy exposure time (mean difference = -21.0 seconds, 95% CI: -42.6 to 0.56, P = 0.07), Clavien I-II (RR = 1.23, 95% CI: 0.71-2.12, P = 0.45) or Clavien III-V complications (RR = 1.04, 95% CI: 0.32-3.42, P = 0.95). CONCLUSIONS: Flexible ureteroscopy has a significantly higher stone-free rate than shock wave lithotripsy, with no difference in complication rate or fluoroscopy exposure time, and significantly higher operative times and hospital stay. However, the current evidence base for this is weak and further randomized trials are needed.
- MeSH
- dítě MeSH
- kameny v močovodu * terapie MeSH
- ledvinové kameny * terapie etiologie MeSH
- lidé MeSH
- litotripse * škodlivé účinky MeSH
- močové kameny * etiologie MeSH
- předškolní dítě MeSH
- prospektivní studie MeSH
- ureteroskopie škodlivé účinky MeSH
- urologie * MeSH
- výsledek terapie MeSH
- Check Tag
- dítě MeSH
- lidé MeSH
- předškolní dítě MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- systematický přehled MeSH
PURPOSE: The European Association of Urology (EAU) has updated its guidelines on clinical best practice in urolithiasis for 2021. We therefore aimed to present a summary of best clinical practice in surgical intervention for patients with upper tract urolithiasis. MATERIALS AND METHODS: The panel performed a comprehensive literature review of novel data up to May 2021. The guidelines were updated and a strength rating was given for each recommendation, graded using the modified Grading of Recommendations, Assessment, Development, and Evaluations methodology. RESULTS: The choice of surgical intervention depends on stone characteristics, patient anatomy, comorbidities, and choice. For shockwave lithotripsy (SWL), the optimal shock frequency is 1.0-1.5 Hz. For ureteroscopy (URS), a postoperative stent is not needed in uncomplicated cases. Flexible URS is an alternative if percutaneous nephrolithotomy (PCNL) or SWL is contraindicated, even for stones >2 cm. For PCNL, prone and supine approaches are equally safe. For uncomplicated PCNL cases, a nephrostomy tube after PCNL is not necessary. Radiation exposure for endourological procedures should follow the as low as reasonably achievable principles. CONCLUSIONS: This is a summary of the EAU urolithiasis guidelines on best clinical practice in interventional management of urolithiasis. The full guideline is available at https://uroweb.org/guidelines/urolithiasis. PATIENT SUMMARY: The European Association of Urology has produced guidelines on the best management of kidney stones, which are summarised in this paper. Kidney stone disease is a common condition; computed tomography (CT) is increasingly used to diagnose it. The guidelines aim to decrease radiation exposure to patients by minimising the use of x-rays and CT scans. We detail specific advice around the common operations for kidney stones.
- MeSH
- ledvinové kameny * chirurgie komplikace MeSH
- lidé MeSH
- perkutánní nefrostomie * metody MeSH
- ureteroskopie metody MeSH
- urolitiáza * chirurgie komplikace MeSH
- urologie * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- směrnice pro lékařskou praxi MeSH
CONTEXT: No algorithm exists for structured follow-up of urolithiasis patients. OBJECTIVE: To provide a discharge time point during follow-up of urolithiasis patients after treatment. EVIDENCE ACQUISITION: We performed a systematic review of PubMed/Medline, EMBASE, Cochrane Library, clinicaltrials.gov, and reference lists according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Fifty studies were eligible. EVIDENCE SYNTHESIS: From a pooled analysis of 5467 stone-free patients, we estimated that for a safety margin of 80% for remaining stone free, patients should be followed up using imaging, for at least 2 yr (radiopaque stones) or 3 yr (radiolucent stones) before being discharged. Patients should be discharged after 5 yr of no recurrence with a safety margin of 90%. Regarding residual disease, patients with fragments ≤4 mm could be offered surveillance up to 4 yr since intervention rates range between 17% and 29%, disease progression between 9% and 34%, and spontaneous passage between 21% and 34% at 49 mo. Patients with larger residual fragments should be offered further definitive intervention since intervention rates are high (24-100%). Insufficient data exist for high-risk patients, but the current literature dictates that patients who are adherent to targeted medical treatment seem to experience less stone growth or regrowth of residual fragments, and may be discharged after 36-48 mo of nonprogressive disease on imaging. CONCLUSIONS: This systematic review and meta-analysis indicates that stone-free patients with radiopaque or radiolucent stones should be followed up to 2 or 3 yr, respectively. In patients with residual fragments ≤4 mm, surveillance or intervention can be advised according to patient preferences and characteristics, while for those with larger residual fragments, reintervention should be scheduled. PATIENT SUMMARY: Here, we review the literature regarding follow-up of urolithiasis patients. Patients who have no stones after treatment should be seen up to 2-3 yr, those with large fragments should be reoperated, and those with small fragments could be offered surveillance with imaging.
- MeSH
- elektronické zdravotní záznamy MeSH
- přístup k informacím MeSH
- zabezpečení počítačových systémů MeSH
- Publikační typ
- úvodníky MeSH
CONTEXT: Endourological procedures frequently require fluoroscopic guidance, which results in harmful radiation exposure to patients and staff. One clinician-controlled method for decreasing exposure to ionising radiation in patients with urolithiasis is to avoid the use of intraoperative fluoroscopy during stone intervention procedures. OBJECTIVE: To comparatively assess the benefits and risks of "fluoroscopy-free" and fluoroscopic endourological interventions in patients with urolithiasis. EVIDENCE ACQUISITION: A systematic review of the literature from 1970 to 2022 was performed using the MEDLINE/PubMed, Embase, and Cochrane controlled trials databases and ClinicalTrials.gov. Primary outcomes assessed were complications and the stone-free rate (SFR). Studies reporting data on ureteroscopy and percutaneous nephrolithotomy (PCNL) were eligible for inclusion. Secondary outcomes were operative duration, hospital length of stay, conversion from a fluoroscopy-free to a fluoroscopic procedure, and requirement for an auxiliary procedure to achieve stone clearance. EVIDENCE SYNTHESIS: In total, 24 studies (12 randomised and 12 observational) out of 834 abstracts screened were eligible for analysis. There were 4564 patients with urolithiasis in total, of whom 2309 underwent a fluoroscopy-free procedure and 2255 underwent a comparative fluoroscopic procedure for treatment of urolithiasis. Pooled analysis of all procedures revealed no significant difference between the groups in SFR (p = 0.84), operative duration (p = 0.11), or length of stay (p = 0.13). Complication rates were significantly higher in the fluoroscopy group (p = 0.009). The incidence of conversion from a fluoroscopy-free to a fluoroscopic procedure was 2.84%. Similar results were noted in subanalyses for ureteroscopy (n = 2647) and PCNL (n = 1917). When only randomised studies were analysed (n = 12), the overall complication rate was significantly in the fluoroscopy group (p < 0.001). CONCLUSIONS: For carefully selected patients with urolithiasis, fluoroscopy-free and fluoroscopic endourological procedures have comparable stone-free and complication rates when performed by experienced urologists. In addition, the conversion rate from a fluoroscopy-free to a fluoroscopic endourological procedure is low at 2.84%. These findings are important for clinicians and patients, as the detrimental health effects of ionising radiation are negated with fluoroscopy-free procedures. PATIENT SUMMARY: We compared treatments for kidney stones with and without the use of radiation. We found that kidney stone procedures without the use of radiation can be safely performed by experienced urologists in patients with normal kidney anatomy. These findings are important, as they indicate that the harmful effects of radiation can be avoided during kidney stone surgery.
- MeSH
- fluoroskopie MeSH
- ledvinové kameny * chirurgie MeSH
- lidé MeSH
- urolitiáza * chirurgie MeSH
- urologie * MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- systematický přehled MeSH
