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Trustworthy ‘Rapid Recommendations’ for Urology

BJU International has a longstanding track record of promoting the principles of evidence-based clinical practice to an international audience of urologists. Recent initiatives include the “guidelines of guidelines” series which appraises and contrasts clinical practice guidelines from different professional organizations on the same topic, for example on microscopic hematuria and non-muscle-invasive bladder cancer. It also co-publishes high quality, urology-relevant guidance by the UK’s National Institute for Health and Care Excellence (NICE), for example on the preoperative testing for elective surgery (https://www.bjuinternational.com/learning-2/urology-guidelines/nice-guidance-routine-preoperative-tests-elective-surgery/).

In collaboration with the MAGIC research and innovation program (www.magicproject.org), BJU International has published its first Rapid Recommendation guidance document on the use of medical expulsive therapy (MET) with alpha-blockers that was triggered by the recent rigorous Cochrane review on the same topic. Its purpose is to provide trustworthy, timely and practical guidance on this topic based on the entire body of evidence, given several recently published trials with contradictory findings. To develop this trustworthy guidance, an international team that included patients with a personal history of ureteral stones, general practitioners (GPs), emergency clinicians, urologists familiar with treating renal colic, epidemiologists, and methodologists followed a rigorous and transparent GRADE-based process in accordance with The National Academy of Science, Engineering and Medicine (formerly: Institute of Medicine) (https://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust/Standards.aspx) standards for trustworthy guidelines. Panel member had no financial conflicts of interest and intellectual and professional conflicts of interests were described and carefully minimized. All meetings were conducted by web conference and the process was completed within 90 days of publication of the Cochrane review, which is co-published in BJU International in this same issue.

Initially pioneered in collaboration with the BMJ for questions of broader interest (https://www.bmj.com/rapid-recommendations) such as the use of corticosteroids for the treatment of a sore throat, this Rapid Recommendation breaks new ground for evidence-based guidance in urology, complementing the efforts by professional organizations such as the European Association of Urology (EAU) and American Urological Association (AUA). Rapid Recommendations stand out for their focus on patient-important outcomes, the use of an explicit and transparent process for moving from evidence to recommendations and its timely development process. Rapid Recommendations provide actionable guidance as well as information on the underlying evidence and supporting judgments that are summarized in an infographic that is easily understood by patients. The Rapid Recommendation on MET is intended to be the first of many to help inform patients, providers and policy-makers but also to seeks to provide a strong impetus for more trustworthy and useful guidelines in urology in general.

 

 

By Philipp Dahm1 2 and Per Olav Vandvik3 4 5

1 Minneapolis VA Medical Center, Urology Section, Minneapolis, MN, USA

2 University of Minnesota, Department of Urology, Minneapolis, MN, USA

3 Norwegian Institute of Public Health, Oslo, Norway

 

Disclosures:

Philipp Dahm serves as Coordinating Editor of Cochrane Urology, is member of the GRADE Working Group and served as a panel member of this Rapid Recommendation project

Per Olav Vandvik is member of the GRADE Working Group, is the leader of the MAGIC Foundation and BMJ Rapid Recommendations project and served as a panel member of this Rapid Recommendation project.

 

Quality matters most where the BJUI and stone disease are concerned

Size (and shape) is important and sometimes strings should be attached, but quality matters most where the BJUI and stone disease are concerned …

The Editor-in-chief of the BJUI has consolidated the journal’s commitment to accepting only the highest quality papers, and this is certainly evident in the upper urinary tract section of this edition, where two studies demonstrate what it takes to be published in the journal nowadays.

In the first article, Kerri Barnes and colleagues from University of Iowa Department of Urology [1] have followed their own department’s earlier retrospective analysis of the benefit of “tethered stents” [2], by analysing the safety and effectiveness of this approach in a prospective, randomised controlled trial. It is often stated that randomised controlled trials are difficult in surgical disciplines, but this study affirms the proverb that “where there’s a will, there’s a way”. Although there was a substantial drop out in the number of patients that could have been included (three quarters of the patients approached for the study declined to be involved as they wished to determine the nature of the stent left in situ), statistical significance was not approached for any of the key concerns that leaving a stent on a string might cause for either the patient or their surgeon.

Furthermore, they have shown that that leaving the strings in place allowed patients to remove their stents significantly earlier (and in the convenience of their own home), than if they had to return to hospital for cystoscopic removal a week or so post-operatively. Despite the established knowledge that stents contribute to postoperative morbidity and can adversely affect quality of life, and the increasing evidence that stents are not required in “uncomplicated” ureteroscopy, it is clear that most urologists continue to leave a stent for a sense of security after performing ureteroscopic stone surgery. Shorter stent dwell times may help reduce the overall burden of stent related symptoms, and it is worth emphasising that none of the patients whose stent was removed at 7 days post operatively had any adverse consequences; neither did the 15% of this group whose stents fell out even earlier. As Fernando and Bultitude [3] comment in the associated editorial, the next question is: “If you are going to place a stent, how long does the stent need to stay for?” Perhaps, in order to emphasise that, where stent bother is concerned, shorter is better, this should be re-phrased as “how little time is enough time for a stent to stay in”…

In the second, Will Finch, from Norfolk and Norwich University Hospital, and his colleagues from Addenbrooke’s Hospital, Cambridge [4], have shown that stone size assessments from CT are most reliably calculated by a 3D-reconstructed stone volume. They have demonstrated that the maximum diameter of a stone tends to predict its overall shape such that a rugby ball-shaped stone (a “prolate ellipsoid”) has the polar diameter as the major axis, whereas a disc-shaped stone (an “oblate ellipsoid”) has the equatorial diameter as its major axis. Stones less than 9mm in diameter tended to be prolate, whilst those of 9–15 mm in diameter tended to be oblate; stones larger than 15 mm in diameter approach the more “random” shape of a scalene ellipsoid, for which the formula used to calculate stone volume (length (l) × width (w) × depth (d) × π × 0.167, which is often simplified to (l × w × d) / 2 in clinical practice) can be used.

However, if this is used for all stones regardless of their size and shape, rugby-ball and disc-like stones of less than 15mm in size are likely to have their volume over-estimated. Accordingly, the authors challenge the guidance of the EAU regarding stone volume calculations [5] to recommend that formulae based on the shape of the stone (π/6*a*a*c* for an oblate and π/6*a*b*b* for a prolate stone – see the paper itself to make sense of this) offer a more accurate assessment of stone volume.

Whilst these formulae are recommended for day-to-day calculations to guide treatment choices, they emphasise that 3D-reconstructed stone volumes should be used to report stone volume in research papers. In an age of stone surgery where CTKUB is so widely used in patients’ imaging assessment, and accepting that stone volume is the key determinant of achieving a stone free patient, this would allow the most accurate comparisons between the effectiveness of different surgical treatments.

Both articles are simple, straightforward, and well conducted studies that apply to the every-day practice of stone surgery. High quality papers are, of course, only really of benefit if they change practice for the better. So why not speak to your radiologist today about adding stone volume assessments to CTKUB reports (and point them to Finch et al. for the evidence) or even do it yourself! And the next time you put in a stent, reassure yourself, and the patient,

that there is no harm, and many benefits, in having some strings attached …

Daron Smith
University College Hospital, London, United Kingdom

References

  1. Barnes KT, Bing MT, Tracy CR. Do ureteric stent extraction strings affect stent-related quality of life or complications after ureteroscopy for urolithiasis: a prospective randomised control trialBJU Int 2014; 113: 605–609
  2. Bockholt N, Wild T, Gupta A, Tracy CR. Ureteric stent placement with extraction strings: no strings attached? BJU Int 2012; 110 (11 Pt C): E1069–1073
  3. Fernando A, Bultitude M. Tether your stents! BJU Int 2014; 113: 517–518
  4. Finch W, Johnston R, Shaida N, Winderbottom A, Wiseman O. Measuring stone volume – three-dimensional software reconstruction or an ellipsoid algebra formula? BJU Int 2014; 113: 610–614
  5. Tiselius HG, Alken P, Buck C et al. European Association of Urology 2008 Guidelines on Urolithiasis. Available at: https://www.uroweb.org/fileadmin/user_upload/Guidelines/Urolithiasis.pdf. Accessed 17 June 2012
 

Article of the week: Plasma vaporization: the new standard for PCNL tract creation?

Every week the Editor-in-Chief selects the 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 accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video procedure by Dr Chiang and colleagues showing tract creation using plasma vaporization.

If you only have time to read one article this week, it should be this one.

 

Randomized and prospective trial comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy

Po Hui Chiang and Hsin Hao Su

Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

OBJECTIVE

• To evaluate the efficacy and safety of plasma vaporization for tract creation in percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

• In this randomized prospective trial we enrolled 65 patients and assigned each to one of two groups: 33 patients were randomly scheduled to undergo plasma vaporization and 32 were scheduled to undergo balloon dilatation for tract creation.

• A bipolar resectoscope mounted with a plasma vaporization button electrode or a traditional balloon dilator were used to create the nephrostomy tract.

RESULTS

• The mean blood loss, mean length of hospital stay and mean operating time, stone-free rates and postoperative complications in the two groups were compared using the t-test or chi-squared test (Fisher’s exact test).

• The plasma vaporization group had a significantly lower mean (SD) decrease in haematocrit level (3.5 [2.8]% vs 6.6 [3.3]%; P = 0.02) and a shorter mean (SD) hospital stay (2.6 [1.2] days vs 5.3 [3.4] days; P = 0.0).

• There were no significant differences in the operating time, stone-free rate or cases of postoperative fever between the two groups.

CONCLUSION

• The plasma vaporization technique is safe, leads to less blood loss than the other techniques, and is a simple solution for creating the nephrostomy tract for PCNL.

 

Read Previous Articles of the Week

 

Editorial: PCNL tract creation: think plasma vaporization

Surgical planning and access are important factors for successful stone-free outcomes in patients undergoing percutaneous nephrolithotomy (PCNL); however, PCNL has a high risk of haemorrhagic complications (reported transfusion rates of up to 12%), which curtail surgery and result in suboptimum outcomes. Access to the pelvicalyceal system remains the major risk for bleeding, often associated with an off-set tract, splitting of the infundibulum/pelvis and/or angulated sheath, and requiring inordinate torque. The ideal tract dilatation method is still being debated, with differing reports on operating time and blood loss (Urol Int 2003, BJU Int 2005J Endourol 2008J Endourol 2011).

The present study evaluates a new method for percutaneous renal access, reporting a shorter operating time, a lower drop in haemoglobin levels and a shorter hospital stay, with no patient requiring transfusion. A patient selection bias might exist, which would explain the low complication rate. Also, the vaporization bubbles and the bleeding could result in difficult views, requiring a high level of expertise in plasma vaporization. The authors did not observe peri-nephric space fluid extravasation or dislodging of the single safety wire. Despite the promising outcome, the reproducibility of this technique remains to be seen, but this is a promising account of reducing bleeding and operating times and maintaining better visualization in PCNL.

Joe Philip
Department of Urology, Southmead Hospital, Westbury-on Trym, and University of Bristol, Bristol, UK

Video: Tract creation using plasma vaporization

Randomized and prospective trial comparing tract creation using plasma vaporization with balloon dilatation in percutaneous nephrolithotomy

Po Hui Chiang and Hsin Hao Su

Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan

OBJECTIVE

• To evaluate the efficacy and safety of plasma vaporization for tract creation in percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

• In this randomized prospective trial we enrolled 65 patients and assigned each to one of two groups: 33 patients were randomly scheduled to undergo plasma vaporization and 32 were scheduled to undergo balloon dilatation for tract creation.

• A bipolar resectoscope mounted with a plasma vaporization button electrode or a traditional balloon dilator were used to create the nephrostomy tract.

RESULTS

• The mean blood loss, mean length of hospital stay and mean operating time, stone-free rates and postoperative complications in the two groups were compared using the t-test or chi-squared test (Fisher’s exact test).

• The plasma vaporization group had a significantly lower mean (SD) decrease in haematocrit level (3.5 [2.8]% vs 6.6 [3.3]%; P = 0.02) and a shorter mean (SD) hospital stay (2.6 [1.2] days vs 5.3 [3.4] days; P = 0.0).

• There were no significant differences in the operating time, stone-free rate or cases of postoperative fever between the two groups.

CONCLUSION

• The plasma vaporization technique is safe, leads to less blood loss than the other techniques, and is a simple solution for creating the nephrostomy tract for PCNL.

 

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