A Holistic Approach to the Management of Kidney Stone Disease.

Épidémiologie de la lithiase urinaire chez les militaires français au cours de l’opération Serval

The incidence of stone disease has been increasing and the risk of recurrent stone formation is high in a pediatric population. It is crucial to use the most effective method with the primary goal of complete stone removal to prevent recurrence from residual fragments. While extracorporeal shock wave lithotripsy (ESWL) is still considered first line therapy in many clinics for urinary tract stones in children, endoscopic techniques are widely preferred due to miniaturization of instruments and evolution of surgical techniques. The standard procedures to treat urinary stone disease in children are the same as those used in an adult population. These include ESWL, ureterorenoscopy, percutaneous nephrolithotomy (standard PCNL or mini-perc), laparoscopic and open surgery. ESWL is currently the procedure of choice for treating most upper urinary tract calculi in a pediatric population. In recent years, endourological management of pediatric urinary stone disease is preferred in many centers with increasing experience in endourological techniques and decreasing sizes of surgical equipment. The management of pediatric stone disease has evolved with improvements in the technique and a decrease in the size of surgical instruments. Recently, endoscopic methods have been safely and effectively used in children with minor complications. In this review, we aim to summarize the recent management of urolithiasis in children.

Urinary stone disease: Great progress with promise for the future

Clinical Trials of the Surgical Management of Urolithiasis: Current Status and Future Needs

Urinary Stone Disease in Adults With Celiac Disease: Prevalence, Incidence and Urinary Determinants

The formation of kidney stones is a complex biologic process involving interactions among genetic, anatomic, dietary, and environmental factors. Traditional lithogenic models were based on urine supersaturation in relation to the activity of crystallization promoters and inhibitors. However, modern research has added new principles such as the “renal epithelial cell response” and the role of inflammation and oxidative stress leading to the development of a “multi-hit hypothesis”. A strong correlation between urinary stones and kidney damage has been well demonstrated by both cohort and case-control studies. The main contributors to chronic kidney damage associated with urinary stones include crystal deposition within the renal parenchyma, associated comorbidities, repeated obstructive and infectious episodes, as well as the potential adverse effects of stone removal procedures. Most hereditary stones may cause high urinary saturation levels promoting obstruction of the Bellini ducts and consequent glomerulosclerosis and interstitial fibrosis in the cortex. These include hereditary hypercalciurias, primary hyperoxalurias, cystinuria, adenine phosphoribosyltransferase (APRT) deficiency (associated with 2,8-dihydroxyadenine lithiasis) and xanthinuria. Complete distal renal tubular acidosis occurs in childhood and presents deafness, rickets, and a short life expectancy. The incomplete form usually manifests in adulthood, primarily with recurrent urinary lithiasis, and less frequently with nephrocalcinosis. In all stone formers stone analysis and a basic metabolic evaluation, including blood biochemistry, urine sediment examination, urinary pH and culture are mandatory, in contrast high-risk stone formers require a more specific metabolic evaluation, including a 24-hour urine sample to measure calcium, phosphate, citrate, oxalate, uric acid, magnesium, sodium and proteinuria. The morpho compositional analysis of kidney stones offers essential insights beyond merely identifying their predominant chemical component. This approach reveals key aspets of the stone formation, such as nucleation sites, crystal growth patterns, and the presence of specific lithogenic processes. The ideal analytical protocol combines stereoscopic microscopy (StM), scanning electron microscopy with energy-dispersive X-ray spectroscopy (SEM-EDS), and, when necessary, Fourier-transform infrared spectroscopy (FTIR). Recurrence prevention and managing residual fragments require complementary strategies such as lifestyle modifications, dietary interventions, and pharmacological therapies. Among pharmacological options, alkaline citrate salts, particularly potassium citrate, are widely used due to their ability to modify urinary chemistry and inhibit stone formation. Recently, novel molecules have been introduced into the management of renal stone disease. Phytate a naturally occurring polyphosphorylated carbohydrate, exibits a potent inhibitory effect on calcium salt’s nucleation, growth, and aggregation. Theobromine, another natural compound, has been shown to effectively inhibit uric acid crystallization. The co-administration of urinary alkalinizing agents, such as potassium citrate, alongside theobromine has been proposed as a therapeutic strategy to optimize uric acid solubility and to reduce the risk of excessive alkalinization and subsequent sodium urate precipitation. Struvite stones are caused by urinary tract infection with urease- producing microorganisms. Their treatment requires specific measures including complete surgical stone removal, short or long-term antibiotic treatment, to maintain urinary acidification to a pH below 6.2, and a urine volume of at least 2 litres/24 hours. L-methionine has been shown to effectively lower urine pH and the relative supersaturation of struvite. An essential aspect of medical management of urinary stone disease is treatment adherence, which depends on perceived benefit, treatment duration, and side effect profile. The side effects of citrate treatment are mild gastrointestinal disorders whereas thiazide diuretics tend to cause hypokalemia-related symptoms and less frequent metabolic and dermatologic side effects. Urease inhibitors for struvite stones and drugs used to enhance cystine solubility are more frequently associated with side effects. The use of smartphone applications can support patients by promoting adequate hydration, adherence to dietary recommendations, and compliance with prophylactic medication. Endoscopic techniques currently play a prevalent role in the removal of renal stones, while extracorporeal shock wave lithotripsy is today marginally used for specific indications. Different technical modalities can be used for percutaneous nephrolithotomy (PCNL), each with its own advantages and disadvntages (standard vs. mini, prone vs. supine, fluoroscopic vs ultrasound-guided). Flexible ureteroscopy or retrograde intrarenal renal surgery (RIRS) has extended its indications due to technological advancements in endoscopes and their accessories. The availability of new laser technologies (thulium fiber laser and pulse-modulated Ho:YAG laser) has enhanced stone fragmentation and dusting capabilities. However, their use exposes the renal parenchyma to high temperatures and pressures which could potentially contribute to renal damage. Factors influencing heat release include laser type and settings, exposure time, stone location, fiber-to-stone distance, irrigation volume and fluid circulation. Reduction of heat release can be achieved by limiting the laser settings to reasonable values or by improving fluid circulation with use of ureteral access sheaths, especially those navigable and equipped with suction. High intrarenal pressure is also closely associated with renal damage. Sustained high pressure or even pressure spikes may increase this risk, highlighting the importance of real-time pressure monitoring through sensors integrated on guidewires, scopes, access sheath and use of innovative platforms regulating irrigation/suction systems. Direct In-Scope Suction (DISS) system was developed to control intrarenal pressure and facilitate the removal of residual fragments. Flexible and Navigable Suction Ureteral Access Sheath (FANS-UAS) is a flexi-bendable UAS equipped with suction capabilities combining mechanical flexibility with continuous irrigation management and stone clearance mechanisms. Ultra-thin scopes (7.5 F) make it easy to perform RIRS without the need for pre-placed double-J stents or with a 9 F sheath achieving more space for stone fragments expulsion or infusion. All these technological advancements have enhanced the efficacy of fURS or RIRS which can be an alternative treatment (salvage fURS) when standard stone management techniques, such as percutaneous nephrolithotomy (PCNL), are contraindicated or fail. Salvage fURS has shown favorable outcomes in complex or high-risk cases, including patients with coagulopathies, morbid obesity, renal anatomical abnormalities (e.g., horseshoe or pelvic kidneys), urinary diversion, calyceal diverticula, and altered urinary tracts. In such scenarios it demonstrated favorable outcomes with stone-free rates ranging from 55.6% to 64% for stones > 2 cm. Although non-invasive, extracorporeal and endoscopic treatments for renal and ureteral stones carry a risk of complications that can be classified according to the Clavien-Dindo system. The complication rate after SWL was estimated at 18.43% for Clavien grade I-II complications (pain, hematuria) and 2.48% for Clavien III-IV complications (hematoma, sepsis). The most frequent complication after RIRS is fever or urinary tract infection observed in 0.2-15% (with 0.1-4.3% of cases of urinary sepsis). Complications after PCNL are more frequent and may include moderate events (hemorrhage requiring transfusion 2-7%, urosepsis 1-2%, bowel injury < 1%) as well as severe events (arteriovenous fistula 0.5-1%, thoracic complications < 1% , loss of access tract 1-3%, death < 0.5%). The risk of bleeding complications is significantly increased in patients on antithrombotic therapy. A personalized, interdisciplinary approach enables optimal decision-making in balancing antithrombotic therapy with surgical safety during urological stone interventions Finally, it must be considered that endourological procedures can be harmful to the surgeons themselves and their team due to exposure to ionizing radiation. For this reason, procedures must be carried out in strict accordance with safety guidelines and regulations to minimize radiation exposure. Safety is vital in any surgical intervention, with efficacy being the next most critical consideration. However, cost-effectiveness should be also considered. Endourology involves high costs largely due to the use of sophisticated equipment that requires frequent renewal due to the continuous rapid technological evolution. Using disposable devices brings numerous benefits but also leads to a further increase in costs. Finally, in the cost-benefit assessment, the rate of reintervention associated with some types of procedures must be considered.

Purpose: With recent technological advances, the indications for retrograde intrarenal surgery (RIRS) have gradually increased. We evaluated the efficacy and treatment outcomes of RIRS for the treatment of renal stones. Materials and Methods: We retrospectively reviewed the medical records of 23 patients with renal stones (7 in the renal pelvis, 9 in the renal calyx, and 7 in the renal diverticulum) treated with RIRS from January 2001 to July 2008. Mean stone burden was 110 mm (range, 9.42-428.6 mm), and all operations were performed under general anesthesia using a semi-rigid ureteroscope in 9 cases, a flexible ureteroscope in 11 cases, and both types simultaneously in 3 cases. The holmium:yttrium-aluminum-garnet (Ho: YAG) laser and the nitinol basket were used for stone fragmentation and retrieval. The patients were followed up postoperatively with KUB (21 cases) or nonenhanced computed tomography (CT; 2 cases). Success was defined as no visible stones on KUB or nonenhanced CT. Results: The mean operating time was 93 minutes (range, 30-205 minutes) and the mean hospital stay was 3.7 days (range, 1-9 days). Of 23 patients, 16 (70%) experienced complete elimination of the stone after only a single intervention. After ancillary extracorporeal shock wave lithotripsy (ESWL), the success rate was increased to 74% (17/23). In the remaining 6 patients, residual stone findings were less than 3 mm and were followed up with X-ray. Conclusions: RIRS is a feasible procedure for treating renal stone disease with minimal complications. The results of our study suggest that RIRS can be recommended as a primary modality in the management of renal stone disease in selected patients such as those with ESWL failure and renal diverticular stones. (Korean J Urol 2009;50:786-790) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Robotic surgery today has made a successful transition into mainstream clinical urological practice, providing minimally invasive surgical treatment options for complex extirpative and reconstructive procedures. It has particularly dominated urologic pelvic surgery including radical prostatectomy, radical cystectomy, and many gynecologic procedures (Menon M, Hemal AK, J Endourol 18(7):611–619, 2004; Hemal AK, Abol-Enein H, Shrivastava A, Shoma AM, Ghoneim MA, Menon M, Urol Clin North Am 31(4):719–729, 2004; Hemal AK, Kolla SB, Wadhwa P, J Urol 180(3):981–985, 2008]. It has successfully been employed in kidney surgery as well, especially donor nephrectomy, partial nephrectomy, and pyeloplasty for ureteropelvic junction obstruction (UPJO) (Phillips CK, Taneja SS, Stifelman MD, J Endourol 19:441–445, 2005; Gettman MT, Neururer R, Bartsch G, Peschel R, Urology 60:509–513, 2002). While urolithiasis is largely treated with shock wave lithotripsy (SWL) and endourological surgery (ureteroscopy [URS] and percutaneous nephrolithotomy [PCNL]), the role of laparoscopy has been explored as an alternative tool in managing urinary stone disease.Laparoscopic ureterolithotomy proved to be a viable alternative to open surgery, helping avoid incision related morbidity in candidates with impacted, large ureteral calculi which had failed an attempt at endourological management (Hemal AK, Goel A, Kumar M, Gupta NP, J Endourol 15(7):701–705, 2001). Laparoscopic stone surgery soon gained acceptance as a complementary minimally invasive technique, specifically to be used in the occasional case considered for open surgery. Stones in anteriorly placed calyceal diverticulum, pelvic stones in ectopic kidneys, assisting percutaneous access in ectopic kidneys formed some of the other indications for laparoscopic stone interventions (Ramakumar S, Segura JW, J Endourol 14(10):829–832, 2000). The use of laparoscopic pyelolithotomy was avidly contested with some authors extolling its virtues as an alternative to PCNL in medium-sized renal calculi unsuitable for SWL therapy and unfavorable calyceal anatomy (Gaur DD, Trivedi S, Prabhudesai MR, Gopichand M, J Laparoendosc Adv Surg Tech A 12(4):299–303, 2002; Yagisawa T, Ito F, Kobayashi C, Onitsuka S, Kondo T, Goto Y, Toma H, J Endourol 15(5):525–528, 2001); while others, though demonstrating its feasibility, were unable to show its superiority over PCNL vis-à-vis operative time and skill required, cosmesis and relative invasiveness (Goel A, Hemal AK, Int Urol Nephrol 35(1):73–76, 2003).The enhanced reconstructive capabilities of the robotic platform added another dimension to laparoscopic management of stone disease. We first explored the use of robot-assisted renal pelvic calculi retrieval during a concomitant pyeloplasty in February 2003 in Egypt. The experience prompted the genesis of usage of robotic-assisted laparoscopic pyelolithotomy, which resulted in the first large series of robotic extended pyelolithotomy (REP) wherein we focused on stone extraction of large renal calculi (partial staghorn calculi), even a complete staghorn calculus (Badani KK, Hemal AK, Fumo M, Kaul S, Shrivastava A, Rajendram AK, Yusoff NA, Sundram M, Woo S, Peabody JO, Mohamed SR, Menon M, World J Urol 24:198–201, 2006). We were successfully able to deal with such large renal pelvic bulky partial staghorn calculi even in cases with intra-renal pelvis, duplicating the technique of extended pyelolithotomy by developing the intrasinus space of Gil-Vernet (Meria P, Milcent S, Desgrandchamps F, Mongiat-Artus P, Duclos JM, Teillac P, Urol Int 75(4):322–326, 2005). The versatility provided by the robot has allowed application of robot-assisted procedures in a variety of indications in managing urinary stone disease at different locations (Table 12.1). Herein we describe our technique of robotic pyelolithotomy and ureterolithotomy.KeywordsRenal PelvisShock Wave LithotripsyPercutaneous NephrolithotomyParacolic GutterFlexible CystoscopeThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

New Frontiers in Stone Disease: Immune Cells

Atypical clinical presentation and management of urinary stone disease in non-verbal non-ambulatory children

47-Year-Old Woman With Bilateral Flank Pain

Clinical pharmacy is one of the specialized areas of pharmacy profession which demands scientific and comprehensive therapeutic knowledge, extensive clinical experience and skills, and collaboration with other healthcare professionals as well as the patients in disease management. The concepts of patient involvement and patient empowerment, patient self-management and patient engagement in health care settings are explored in many studies. The PubMed search undertaken in March 2019 by using the keywords of ‘patient involvement,’ ‘disease management,’ and ‘clinical pharmacy’ revealed 581 publications, of those 268 were published in the last five years and 95 were review articles. Another search made by using the words of ‘patient empowerment’ and ‘clinical pharmacy,’ and the results were even increased to 735 articles. A patient-centered approach is the cornerstone of the provision of clinical pharmacy services in chronic disease management. The patient’s ability in problem-solving can be enhanced through teaching general skills and providing access to appropriate counseling or supervision. Therefore, patients become responsible for many issues, such as describing their symptoms and expressing their concerns properly, using specific self-management practices, and applying preventative approaches in their disease management. During the disease management process, roles and responsibilities of healthcare professionals and patients should be specified, and patients become less severely incapacitated by disease consequences, well-informed about their condition and medications, and have higher self-esteem to improve their condition or prevent their condition becoming worse.

Exome Sequencing in Saudi Arabian Pediatric Kidney Disease Single-Center Cohort

Nephrolithiasis is highly prevalent across all demographic groups in the Western world and beyond, and its incidence rates are rising. In addition to the morbidity of the acute event, stone disease often becomes a lifelong problem that requires preventative therapy to diminish ongoing morbidity. Across the majority of stone types, increased fluid intake and targeted dietary modifications are mainstays of therapy. Specific dietary interventions associated with reduced calcium stone risk include adequate dietary calcium intake and restriction of sodium, protein, and oxalate intake, among others. Pharmaceutical therapy may be required if lifestyle changes are insufficient to minimize risk of stone recurrence, and must be targeted to the specific metabolic abnormalities portending risk for a given patient. Therapeutic options for idiopathic calcium stone disease include thiazides, citrate salts, and uric acid-lowering agents. Alkali salts are also the treatment of choice for uric acid stone disease. Management of struvite stone disease is largely surgical, but acetohydroxamic acid is a proven second line therapy. Cystinuria requires lifestyle modifications and may call for thiol-binding agents. Significant heterogeneity of the clinical population with stone disease has previously limited opportunities for large randomized controlled trials. However, as clinical phenotypes and genotypes are increasingly clarified, there are mounting opportunities for targeted randomized controlled trials in stone prevention. In the meantime, the currently available evidence for both lifestyle and pharmacologic interventions is reviewed herein.

Background: Renal calculi is mineral deposit in the renal calyces and pelvis that are found free or attached to the renal papillae. Management of kidney stone disease in pediatric population is a challenging condition in urology practice. While the incidence of kidney stone is increasing in those group, technological innovations have contributed to the development of minimally invasive treatment of urinary stone disease such as mini-percutaneous nephrolithotomy (mini-PCNL), micro-PCNL, ultra mini-PCNL. Aim: To find the frequency of stone clearance and post op hematoma after micro PCNL in pediatric patients with renal stones. Place and duration of study: Department of Urology, Shaikh Zayed Hospital, Lahore from 25-01-2020 to 25-07-2020. Methodology: After approval from the hospital ethical committee, 60 all the children of 18 years presenting in Department of Urology fulfilling the inclusion criteria were included. An informed consent was obtained from patients. Before performing micro PCNL renal stone was confirmed on CT-Scan KUB plain. After proper selection of the patients, they were prepared for surgery. After preparation patients were put on list for micro-PCNL. Surgery was performed. Post operatively CT-Scan KUB plain was performed to see the stone clearance four weeks after surgery. Post hematoma was noted according to Clavien Grading Scoring. Results: Out of 60 patients, 19(31.7%) were in group ≤10 years of age whereas 41(68.3%) in were in group 11-18 years of age, mean age was calculated as 12.90±3.16 years. There were 44(73.3%) were male whereas 16(26.7%) were females. Frequency of stone clearance was 56(93.33%) and post op hematuria was 4(6.66%) after micro PCNL in pediatric patients with renal stones. Conclusion: We found that, after Micro PCNL in pediatric patients with renal stones there were good stone clearance rate and less hematuria. So micro PCNL is good technique for stone clearance and less complications occurred. Keywords: Urinary tract stone, PCNL, Renal Calculi.