Tag: #BJUI

Article of the week: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

January 29, 2020/by Manuel Armas-Phan

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a visual abstract prepared by a trainee urologist; we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, we recommend this one.

Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

Manuel Armas-Phan*, David T. Tzou*^†, David B. Bayne*, Scott V. Wiener*, Marshall L. Stoller* and Thomas Chi*

*Department of Urology, University of California, San Francisco, CA and ^†Division of Urology, University of Arizona, Tucson, AZ, USA

Read the full article

Abstract

Objectives

To compare clinical outcomes in patients who underwent percutaneous nephrolithotomy (PCNL) with renal tract dilatation performed under fluoroscopic guidance vs renal tract dilatation with ultrasound guidance.

Patients and Methods

We conducted a prospective observational cohort study, enrolling successive patients undergoing PCNL between July 2015 and March 2018. Included in this retrospective analysis were cases where the renal puncture was successfully obtained with ultrasound guidance. Cases were then grouped according to whether fluoroscopy was used to guide renal tract dilatation or not. All statistical analyses were performed using Stata version 15.1 including univariate (Fisher’s exact test, Welch’s t‐test) and multivariate analyses (binomial logistic regression, ordinal logistic regression, and linear regression).

Results

A total of 176 patients underwent PCNL with successful ultrasonography‐guided renal puncture, of whom 38 and 138 underwent renal tract dilatation with fluoroscopic vs ultrasound guidance, respectively. There were no statistically significant differences in patient age, gender, body mass index (BMI), preoperative hydronephrosis, stone burden, procedure laterality, number of dilated tracts, and calyceal puncture location between the two groups. Among ultrasound tract dilatations, a higher proportion of patients were placed in the modified dorsal lithotomy position as opposed to prone, and a significantly shorter operating time was observed. Only modified dorsal lithotomy position remained statistically significant after multivariate regression. There were no statistically significant differences in postoperative stone clearance, complication rate, or intra‐operative estimated blood loss. A 5‐unit increase in a patient’s BMI was associated with 30% greater odds of increasingly severe Clavien–Dindo complications. A 5‐mm decrease in the preoperative stone burden was associated with 20% greater odds of stone‐free status. No variables predicted estimated blood loss with statistical significance.

Conclusions

Renal tract dilatation can be safely performed in the absence of fluoroscopic guidance. Compared to using fluoroscopy, the present study demonstrated that ultrasonography‐guided dilatations can be safely performed without higher complication or bleeding rates. This can be done using a variety of surgical positions, and future studies centred on improving dilatation techniques could be of impactful clinical value.

Editorial: Zero‐radiation stone treatment

January 29, 2020/by Matthew Bultitude

In this month’s BJUI, Armas‐Phan et al. [1] report on a prospective observational trial of fluoroscopic vs ultrasound (US)‐guided tract dilatation during percutaneous nephrolithotomy (PCNL). A total of 176 patients underwent successful initial US‐only guided puncture; of these patients, 138 had US‐only dilatation, while in 38 fluoroscopy was required. The authors found no difference in patient factors (e.g. age, gender, body mass index [BMI]) or stone factors (hydronephrosis, stone burden, number of tracts or puncture location). On multivariate analysis, US dilatation was more likely to be performed in the modified dorsal lithotomy position (compared to prone), but there was no significant difference in important outcomes such as stone clearance, complication rates or blood loss.

Whilst only reporting on access (and not necessarily dilatation), the Clinical Research Office of the Endourological Society PCNL Global Study shows us that worldwide fluoroscopic access is by far the most common (88.3% of cases) [2] and there are relatively few reports of US‐guided dilatation in the literature. The technique does produce technical challenges as the surgeon needs to confidently identify the depth of the dilators or balloon and be sure of its location relative to calyceal anatomy. Whilst dilating short is not usually a problem as simply re‐dilating can be done, dilating too far carries serious risk of perforation of the pelvicalyceal system and vascular injury. The authors’ described technique does rely on good kidney and guidewire visualisation, and if this is not possible then fluoroscopy is used instead. Thus, even in this series with experts at this technique, 38 (22%) underwent fluoroscopic dilatation after US‐guided puncture, and of the 138 with intended US dilatation, seven (5%) were converted to fluoroscopy. Furthermore, 115 patients never entered this series as they underwent initial fluoroscopic‐guided puncture. Thus, it is important to realise that this is a series of select patients being treated by expert enthusiasts of this technique and fluoroscopy should be available in the operating theatre, as it is not possible to do this technique for all patients. In particular, obesity limits the visualisation under US and the authors have previously shown that renal access drops from 76.9% of normal‐weight patients (BMI <25 kg/m²) to 45.6% for those classified as obese (BMI >30 kg/m²) [3]. An alternative strategy to avoid radiation is to use endoscopic combined intrarenal surgery (ECIRS), as the depth of dilatation can be monitored by direct visualisation via the flexible ureteroscope.

Patients and healthcare professionals are increasingly aware of the risks posed by ionising radiation. Ferrandino et al. [4] analysed radiation exposure of patients presenting with acute stone episodes in an American setting. The mean dose was a staggering 29.7 mSv and 20% of patients received >50 mSV. There is also awareness of risk to the operating staff from endourological procedures and although doses are relatively low [5], these can accumulate during a lifetime of operating, with risks of not only malignancy but also cataract formation [6]. Whilst I am sure we all wear protective lead gowns in the operating theatre, how many people wear lead glasses? A recent study showed that, at typical workload, the annual dose to the lens of the eye was 29 mSv in interventional endourology [7].

As urologists, we should all be aware of these risks and follow the ALARA (As Low As Reasonably Achievable) principals of keeping doses to a minimum. Thus, this paper [1] is particularly welcome and shows zero‐radiation procedures can be safely performed. The authors now attempt this technique for all PCNL procedures and achieve US‐only puncture and dilatation in over half of their patients. Hopefully, this paper will inspire us all to look at reducing or eliminating radiation usage in our stone procedures and this will be good for patients and surgeons alike.

by Matt Bultitude

References

Armas‐Phan M, Tzou DT, Bayne DB et al. Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy. BJUI 2019; 125: 284-91
De La Rosette J, Assimos D, Desai M et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol 2011; 25: 11– 7
Usawachintachit M, Masic S, Chang H, Allen I, Chi T. Ultrasound guidance to assist percutaneous nephrolithotomy reduces radiation exposure in obese patients. Urology 2016; 98: 32– 8
Ferrandino MN, Bagrodia A, Pierre SA et al. Radiation exposure in the acute and short‐term management of urolithiasis at 2 academic centers. J Urol 2009; 181: 668– 72
Galonnier F, Traxer O, Rosec M et al. Surgical staff radiation protection during fluoroscopy‐guided urologic interventions. J Endourol 2016; 30: 638– 43
Hartmann J, Distler F, Baumuller M et al. Risk of radiation‐induced cataracts: investigation of radiation exposure to the eye lens during endourologic procedures. J Endourol 2018; 32: 897– 903
Hristova‐Popova J, Zagorska A, Saltirov I et al. Risk of radiation exposure to medical staff involved in interventional endourology. Radiat Prot Dosimetry 2015; 165: 268– 71

Visual abstract: Ultrasound guidance can be used safely for renal tract dilatation during percutaneous nephrolithotomy

January 29, 2020/by Cora Griffin

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What’s the diagnosis?

January 24, 2020/by Admin

Images from Chen et al, BJUI 2019 who are assessing pelvic anatomy and outcomes from robotic prostatectomy.

No such quiz/survey/poll

February 2020 – about the cover

January 23, 2020/by Admin

One of the authors of February’s Article of the Month (Understanding volume–outcome relationships in nephrectomy and cystectomy for cancer: evidence from the UK Getting it Right First Time programme) is from Wakefield in Yorkshire, UK.

The cover image shows the moat and ruins of Sandal Castle, which is located in Sandal Magna on the outskirts of Wakefield. The castle was originally built of timber by the 2nd Earl of Surrey, William Warenne, early in the 12th century. In the 13th century, the timber motte-and-bailey castle was rebuilt in stone by a later member of the Warenne family. The castle was maintained until the late 14oos, with the Battle of Wakefield taking place nearby, and a brief resurgence whilst in Royalist hands during the English civil war, but eventually the stone was taken for use in local buildings leaving the ruin you can see today.

There is a good view of the cathedral town of Wakefield, situated on the River Calder, from the hill at Sandal Castle.

Article of the week: A randomized trial comparing bipolar TUVP with GreenLight laser PVP for treatment of small to moderate benign prostatic obstruction

January 22, 2020/by Fady K. Ghobrial

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community and a podcast prepared by one of our Resident podcasters; we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, we recommend this one.

A randomized trial comparing bipolar transurethral vaporization of the prostate with GreenLight laser (xps‐180watt) photoselective vaporization of the prostate for treatment of small to moderate benign prostatic obstruction: outcomes after 2 years

Fady K. Ghobrial, Ahmed Shoma, Ahmed M. Elshal, Mahmoud Laymon, Nasr El-Tabey, Adel Nabeeh and Ahmed A. Shokeir

Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt

Read the full article

Abstract

Objective

To test the non‐inferiority of bipolar transurethral vaporization of the prostate (TUVP) compared to GreenLight laser (GL) photoselective vaporization of the prostate (PVP) for reduction of benign prostatic hyperplasia‐related lower urinary tract symptoms in a randomized trial.

Methods

Eligible patients with prostate volumes of 30–80 mL were randomly allocated to GL‐PVP (n = 58) or bipolar TUVP (n = 61). Non‐inferiority of symptom score (International Prostate Symptom Score [IPSS]) at 24 months was evaluated. All peri‐operative variables were recorded and compared. Urinary (IPSS, maximum urinary flow rate and post‐void residual urine volume) and sexual (International Index of Erectile Function‐15) outcome measures were evaluated at 1, 4, 12 and 24 months. Need for retreatment and complications, change in PSA level and health resources‐related costs of both procedures were recorded and compared.