Faculty Bibliography

INTRODUCTION/UNASSIGNED:The area of paediatric endourology is unique and is recognised to be challenging, and it requires a certain level of focused training and expertise. Our aim was to conduct a worldwide survey in order to gain an overview regarding the current practice patterns for minimally invasive treatments of paediatric upper urinary tract stone patients. MATERIAL AND METHODS/UNASSIGNED:The survey was distributed between December 2021 and April 2022 through urology sections and societies in United Kingdom, Latin America and Asia. The survey was made up of 20 questions and it was distributed online using the free online Google Forms (TM). RESULTS/UNASSIGNED:221 urologists answered the survey with 56 responses each from India, South America and UK and 53 responses from the rest of Europe (15 countries). In total, 163 responders (73.7%) managed paediatric stone patients in their daily practice. Of the responders, 60.2% were adult urologists and 39.8% were paediatric urologists. 12.9% adult urologists and 20.4% paediatric urologists run independent clinics while some run combined adult and paediatric clinics sometimes with the support of the nephrologists. Only 33.9% urologists offered all surgical treatments [extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy (URS) and retrograde intrarenal surgery (RIRS)]. CONCLUSIONS/UNASSIGNED:Treatment of paediatric stones can vary according to country and legislations. Based on the results of this survey, minimally invasive methods such as URS and mini PCNL seem to have become more popular. In most institutions a collaboration exists between adult and paediatric urologists, which is the key for a tailored decision making, counselling and treatment success.

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

INTRODUCTION:Percutaneous nephrolithotomy (PCNL) is one of the main approaches for the treatment of large and complex stones in pediatric patients. The patient position for PCNL has been classically divided into prone or supine and the prone position is more commonly used. One of the most feared complications of this surgical technique is colon injury and the objective of this work is to evaluate the incidence of retrorenal colon (RRC) both supine and prone position, in pediatric patients, through radiological images. MATERIALS AND METHOD:A retrosepctive review was performed of all abdominal CT scans performed in one center, in patients under 18 years since 2017 to 2019. The ideal path for percutaneous puncture was traced in the upper, middle, and lower calyces of both kidneys in the prone and supine positions and contact with the kidney and adjacent organs was evaluated, with a uro-radiologist. Chi-square test and Student's t test were applied. RESULTS:50 CT-scans were performed on 44 children. Patients had a mean age of 12.6 years and 71.4% were male. Twenty-five scans were performed in the prone and 25 in the supine position. The incidence of RRC for the left kidney (LK) was significantly higher in the lower calyx in prone position than in the supine position, 28% vs 4% (p = 0.049), and the right kidney (RK) presented RRC only in the prone position. The liver was the most frequent retrorenal organ (97.7%) for the RK, with a non-significant difference by position, while for the LK the spleen was the most frequent (61.1%). DISCUSSION:Colon injury is one of the most morbid complication in PCNL and one of the reasons to perform a CT scan before surgery, on which its incidence appears to be <1% in adults. The present study revealed RRC to be present in three (12%) patients in the supine position and seven (28%) patients in the prone position (p=0.15). These results were slightly higher from those reported in adults (supine: 1.7%-10%; prone: 6.8%-20%), but there are no reports in the literature on this issue to allow appropriate comparison. This is the first study to attempt to assess the incidence of RRC in children according to position. CONCLUSION:The incidence of RRC for an ideal puncture was significantly higher in the lower calyx of the left kidney in the prone position than in the supine position, and in the right kidney, the RRC only occurred in the prone position.

BACKGROUND:Endourologic interventions for urolithiasis in patients with anomalous kidneys can be challenging, and comparisons between these interventions are not well studied. We aim to compare the safety, outcomes and complications of retrograde intrarenal surgery (RIRS) versus percutaneous nephrolithotomy (PCNL) in patients with urolithiasis in anomalous kidneys. METHODS:A propensity score-matched pair analysis (PSM) was performed on pooled patient data from 20 centers. 569 patients with anomalous kidneys (horseshoe kidney [HSK], ectopic kidney, malrotated kidney) and urolithiasis who received either PCNL or RIRS as the primary modality of intervention from 2010 to 2020 were analyzed. Patients were matched based on calculated propensity scores by a regression model using age, sex, comorbidities, stone size, and renal anomaly type as co-variates. Multivariate logistic regression of factors (mode of treatment [PCNL or RIRS], comorbidities, stone size) and their effects on outcomes of stone-free rate (SFR), need to abandon surgery due to intraoperative difficulty, postoperative hematuria and sepsis and were analyzed when applicable. RESULTS:After PSM, there were a total of 127 pairs in each group. Overall, PCNL conferred a higher SFR compared to RIRS (OR=3.69, 95% CI 1.91-7.46, P<0.001), particularly in HSK (OR=3.33, 95% CI 1.22-9.99, P=0.023), and ectopic kidneys (OR=18.10, 95% CI 3.62-147.63, P=0.002), with no significant difference in malrotated kidneys. There was no significant difference in postoperative sepsis observed. Surgery was abandoned more often in RIRS than PCNL (6.3% vs. 0%, P=0.014). Although PSM provides a robust analysis due to baseline differences in the unmatched cohorts, this study was limited by an inevitable degree of selection bias. CONCLUSIONS:While both modalities are safe and efficacious, PCNL yields better SFR than RIRS in patients with anomalous kidneys, with no difference in postoperative sepsis rates. Patients may benefit from personalized management best carried out in high volume endourology centers.

BACKGROUND:Retrograde intrarenal surgery (RIRS) has become the preferred treatment modality for nephrolithiasis. However, because of ongoing uncertainties regarding the optimal perioperative management, operative technique, and postoperative follow-up, as well as a lack of standardization for outcome reporting, consensus is needed to achieve more uniform clinical practice worldwide. OBJECTIVE:To develop recommendations for RIRS on the basis of existing data and expert consensus. DESIGN, SETTING, AND PARTICIPANTS:A protocol-driven, three-phase study was conducted by the European Association of Urology Section of Urolithiasis (EULIS) and the International Alliance of Urolithiasis (IAU). The process included: (1) a nonsystematic review of the literature to define domains for discussion; (2) a two-round modified Delphi survey involving experts in this field; and (3) an additional group meeting and third-round survey involving 64 senior representative members to formulate the final conclusions. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:The results from each previous round were returned to the participants for re-evaluation of their decisions during the next round. The agreement threshold was set at 70%. RESULTS AND LIMITATIONS:The panel included 209 participants who developed 29 consensus statements on the following topics of interest: (1) perioperative infection management; (2) perioperative antithrombotic therapy; (3) fundamentals of the operative technique; and (4) standardized outcome reporting. Although this consensus can be considered as a useful reference for more clinically oriented daily practice, we also acknowledge that a higher level of evidence from further clinical trials is needed. CONCLUSIONS:The consensus statements aim to guide and standardize clinical practice and research on RIRS and to recommend standardized outcome reporting. PATIENT SUMMARY:An international consensus on the best practice for minimally invasive surgery for kidney stones was organized and developed by two international societies. It is anticipated that this consensus will provide further guidance to urologists and may help to improve clinical outcomes for patients.

Ureteral access sheaths (UASs) are part of urologist's armamentarium when performing retrograde intrarenal surgery (RIRS). Recently, the world of RIRS has changed dramatically with the development of three game-changers: thulium fiber laser (TFL), smaller size single use digital flexible ureterosopes and intraoperative intrarenal pressure (IRP) measurement devices. We aimed to clarify the impact of UASs on IRP, complications and SFRs and put its indications in perspective of these three major technological improvements. A systematic review of the literature using the Medline, Scopus and Web of Science databases was performed by two authors and relevant studies were selected according to PRISMA guidelines. Recent studies showed that using a UAS lowers IRP and intrarenal temperature by increasing irrigation outflow during RIRS. Data on the impact of a UAS on SFRs, postoperative pain, risk of infectious complications, risk of ureteral strictures and risk of bladder recurrence of urothelial carcinoma after diagnostic RIRS were inconclusive. Prestenting for at least one week resulted in ureteral enlargement, while the influence of pre-operative administration of alpha-blockers was unclear. Since TFL, smaller single use digital ureteroscopes and devices with integrated pressure-measuring and aspiration technology seemed to increase SFRs and decrease pressure and temperature related complications, indications on the use of a UAS may decrease in the near future.

PURPOSE/OBJECTIVE:To evaluate the current practice of percutaneous nephrolithotomy (PCNL), conducting a worldwide survey among urologists with a special interest in endo-urology. METHODS:A 22-question survey was specifically developed by the European Association of Urology (EAU) young academic urologists (YAU) and uro-technology (ESUT) groups and globally distributed via SurveyMonkey to almost 2000 members of Endourology Society. The questionnaire included questions dedicated to the demographics and general practice of the participating urologists. RESULTS:In total, 441 responses (male/female ratio - 418/23) were received. A comparatively higher percentage of specialists (56.2%) practiced in academic institutions and had specific endo-urological fellowship training (56.7%). The classical prone PCNL remained the most practiced approach among the surveyed specialists, 47.7% stated to always do prone PCNLs, while 51.8% of respondents used multiple positioning options as required. The PCNL tract was mostly performed by urologists (84.3%) and fluoroscopic guidance was still predominantly used by 74.5% of respondents. The most practiced tract dilation method was balloon dilator used by 42% of respondents. Most of the surveyed urologists had ultrasonic, pneumatic or laser lithotripsy devices in their armamentarium. The use of some form of post-procedural drainage was reported in 85.1% of respondents, whereas tubeless PCNL remained a fairly uncommon practice. CONCLUSION/CONCLUSIONS:The majority of urologists still use prone positioning, get their own access under fluoroscopy guidance and use a balloon for tract dilation. However, we also identified that when necessary, urologists will deviate from routine practice and change strategy, adopting other approaches for PCNL.

PURPOSE/OBJECTIVE:To evaluate the decompression of the pelvicalyceal system between urologists and radiologists. METHODS:A survey was distributed to urologists and to radiologists comparing double-J stent (DJS), percutaneous nephrostomy (PN) and primary ureteroscopy (URS) for three clinical scenarios (1-febrile hydronephrosis; 2-obstruction and persistent pain; 3-obstruction and anuria) before and after reading literature The survey included perception on radiation dose, cost and quality of life (QoL). RESULTS:Response rate was 40% (366/915). 93% of radiologists believe that DJS offers a better QOL compared to 70.6% of urologists (p = 0.006). 28.4% of urologists consider PN to be more expensive compared to 8.9% of radiologists (p = 0.006). 75% of radiologists believe that radiation exposure is higher with DJS as opposed to 33.9% of urologists. There was not a difference in the decompression preference in the first scenario. After reading the literature, 28.6% of radiologists changed their opinion compared to 5.2% of urologists (p < 0.001). The change favored DJS. In the second scenario, responders preferred equally DJS and they did not change their opinion. In the third scenario, 41% of radiologists chose PN as opposed to 12.6% of urologists (p < 0.001). After reading the literature, 17.9% of radiologists changed their opinion compared to 17.9% of urologists (p < 0.001), in favor of DJS. Although the majority of urologists (63.4%) consistently perform primary URS, only 3, 37 and 21% preferred it for the first, second and third scenarios, respectively. CONCLUSION/CONCLUSIONS:The decision on the type of drainage of a stone-obstructing hydronephrosis should be individualized.