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Athanasios Papatsoris et al., 2024: Management of urinary stones: state of the art and future perspectives by experts in stone disease

Athanasios Papatsoris 1 , Alberto Budia Alba 2 , Juan Antonio Galán Llopis 3 , Murtadha Al Musafer 4 , Mohammed Alameedee 5 , Hammad Ather 6 , Juan Pablo Caballero-Romeu 7 , Antònia Costa-Bauzá 8 , Athanasios Dellis 9 , Mohamed El Howairis 10 , Giovanni Gambaro 11 , Bogdan Geavlete 12 , Adam Halinski 13 , Bernhard Hess 14 , Syed Jaffry 15 , Dirk Kok 16 , Hichem Kouicem 17 , Luis Llanes 18 , Juan M Lopez Martinez 19 , Elenko Popov 20 , Allen Rodgers 21 , Federico Soria 22 , Kyriaki Stamatelou 23 , Alberto Trinchieri 24 , Christian Tuerk 25
12nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens; U-merge Scientific Office.
2Urology Department, La Fe University and Polytechnic Hospital, Valencia.
3Department of Urology. General University Hospital Dr. Balmis, Alicante.
4University of Basrah, Basrah.
5Diwaniya Teaching Hospital.
6Aga Khan University, Karachi.
7Department of Urology, Miguel Hernández University, Alicante.
8Laboratory of Renal Lithiasis Research, University Institute of Health Sciences Research (IUNICS-IdISBa), University of Illes Balears, Palma de Mallorca.
92nd Department of Surgery, Aretaieion Academic Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens.
10Imperial college, London University, London.
11Division of Nephrology, Department of Medicine, University Hospital of Verona.
12"Carol Davila" University of Medicine and Pharmacy & "Saint John" Emergency Clinical Hospital, Bucharest.
13Private Medical Center "Klinika Wisniowa" Zielona Gora.
14Internal Medicine & Nephrology, KidneyStoneCenter Zurich, Klinik Im Park, Zurich.
15University Hospital Galway.
16Saelo Scientific Support, Oegstgeest.
17Private Clinic, Clinique Les Pins, Setif.
18Urology Department, University Hospital of Getafe, Getafe, Madrid.
19Dept of Urology, University of Barcelona Clinic Hospital, Barcelona.
20Department of Urology, UMHAT "Tzaritza Yoanna-ISUL", Medical University, Sofia.
21University of Cape Town.
22Experimental Surgery Department, Ramón y Cajal University Hospital, Madrid.
23MESOGEIOS Nephrology Center, Haidari Attica and NEPHROS.EU Private Clinic, Athens.
24School of Urology, University of Milan; U-merge Scientific Office.
25Urologic Department, Sisters of Charity Hospital and Urologic Praxis, Wien.

Abstract

Aim: To present state of the art on the management of urinary stones from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024. Options of treatment: The surgical treatment modalities of renal and ureteral stones are well defined by the guidelines of international societies, although for some index cases more alternative options are possible. For 1.5 cm renal stones, both m-PCNL and RIRS have proven to be valid treatment alternatives with comparable stone-free rates. The m-PCNL has proven to be more cost effective and requires a shorter operative time, while the RIRS has demonstrated lower morbidity in terms of blood loss and shorter recovery times. SWL has proven to be less effective at least for lower calyceal stones but has the highest safety profile. For a 6mm obstructing stone of the pelviureteric junction (PUJ) stone, SWL should be the first choice for a stone less than 1 cm, due to less invasiveness and lower risk of complications although it has a lower stone free-rate. RIRS has advantages in certain conditions such as anticoagulant treatment, obesity, or body deformity. Technical issues of the surgical procedures for stone removal: In patients receiving antithrombotic therapy, SWL, PCN and open surgery are at elevated risk of hemorrhage or perinephric hematoma. URS, is associated with less morbidity in these cases. An individualized combined evaluation of risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. Pre-interventional urine culture and antibiotic therapy are mandatory although UTI treatment is becoming more challenging due to increasing resistance to routinely applied antibiotics. The use of an intrarenal urine culture and stone culture is recommended to adapt antibiotic therapy in case of postoperative infectious complications. Measurements of temperature and pressure during RIRS are vital for ensuring patient safety and optimizing surgical outcomes although techniques of measurements and methods for data analysis are still to be refined. Ureteral stents were improved by the development of new biomaterials, new coatings, and new stent designs. Topics of current research are the development of drug eluting and bioresorbable stents. Complications of endoscopic treatment: PCNL is considered the most invasive surgical option. Fever and sepsis were observed in 11 and 0.5% and need for transfusion and embolization for bleeding in 7 and 0.4%. Major complications, as colonic, splenic, liver, gall bladder and bowel injuries are quite rare but are associated with significant morbidity. Ureteroscopy causes less complications, although some of them can be severe. They depend on high pressure in the urinary tract (sepsis or renal bleeding) or application of excessive force to the urinary tract (ureteral avulsion or stricture). Diagnostic work up: Genetic testing consents the diagnosis of monogenetic conditions causing stones. It should be carried out in children and in selected adults. In adults, monogenetic diseases can be diagnosed by systematic genetic testing in no more than 4%, when cystinuria, APRT deficiency, and xanthinuria are excluded. A reliable stone analysis by infrared spectroscopy or X-ray diffraction is mandatory and should be associated to examination of the stone under a stereomicroscope. The analysis of digital images of stones by deep convolutional neural networks in dry laboratory or during endoscopic examination could allow the classification of stones based on their color and texture. Scanning electron microscopy (SEM) in association with energy dispersive spectrometry (EDS) is another fundamental research tool for the study of kidney stones. The combination of metagenomic analysis using Next Generation Sequencing (NGS) techniques and the enhanced quantitative urine culture (EQUC) protocol can be used to evaluate the urobiome of renal stone formers. Twenty-four hour urine analysis has a place during patient evaluation together with repeated measurements of urinary pH with a digital pH meter. Urinary supersaturation is the most comprehensive physicochemical risk factor employed in urolithiasis research. Urinary macromolecules can act as both promoters or inhibitors of stone formation depending on the chemical composition of urine in which they are operating. At the moment, there are no clinical applications of macromolecules in stone management or prophylaxis. Patients should be evaluated for the association with systemic pathologies.

Prophylaxis: Personalized medicine and public health interventions are complementary to prevent stone recurrence. Personalized medicine addresses a small part of stone patients with a high risk of recurrence and systemic complications requiring specific dietary and pharmacological treatment to prevent stone recurrence and complications of associated systemic diseases. The more numerous subjects who form one or a few stones during their entire lifespan should be treated by modifications of diet and lifestyle. Primary prevention by public health interventions is advisable to reduce prevalence of stones in the general population. Renal stone formers at "high-risk" for recurrence need early diagnosis to start specific treatment. Stone analysis allows the identification of most "high-risk" patients forming non-calcium stones: infection stones (struvite), uric acid and urates, cystine and other rare stones (dihydroxyadenine, xanthine). Patients at "high-risk" forming calcium stones require a more difficult diagnosis by clinical and laboratory evaluation. Particularly, patients with cystinuria and primary hyperoxaluria should be actively searched.

Future research: Application of Artificial Intelligence are promising for automated identification of ureteral stones on CT imaging, prediction of stone composition and 24-hour urinary risk factors by demographics and clinical parameters, assessment of stone composition by evaluation of endoscopic images and prediction of outcomes of stone treatments. The synergy between urologists, nephrologists, and scientists in basic kidney stone research will enhance the depth and breadth of investigations, leading to a more comprehensive understanding of kidney stone formation.

Arch Ital Urol Androl. 2024 Jun 27;96(2):12703. doi: 10.4081/aiua.2024.12703. PMID: 38934520

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Comments 1

Peter Alken on Friday, 27 September 2024 11:00

“The purpose of this article is to accumulate up-to-date available knowledge and surgical tips and tricks from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024.”
It is a kind of a small book with 125 references on all aspects of urolithiasis devoted to the late Nor Buchholz who organized the ESD congresses.

Peter Alken

“The purpose of this article is to accumulate up-to-date available knowledge and surgical tips and tricks from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024.” It is a kind of a small book with 125 references on all aspects of urolithiasis devoted to the late Nor Buchholz who organized the ESD congresses. Peter Alken
Thursday, 05 December 2024